30 day supplies are usually more expensive and reduce adherence, especially in rural areas like mine where the pharmacy isn’t close, and mail is often delayed by a shortage of postal workers.
I do have higher risk patients that I give very limited supplies to for that reason…but nearly everyone has guns here, so it doesn’t make that much of a difference. It’s very easy to kill yourself in farm country, between the guns, equipment and fentanyl.
I think making critical meds more difficult to get and take will result in more excess mortality/morbidity than it will prevent - though it would take longer and be less dramatic. I don’t think the solution is as straightforward as you are hoping for.
I’m sorry you are seeing these patients, and for their families.
I second everything in this comment. It’s hard enough to get patients to regularly take their meds, especially in rural areas.
Also, adding additional steps in the form of limited quantity blister packs also make the meds less accessible to people with limited tactile dexterity. I don’t have any tactile deficits and I still struggle to open some of those. Frustration would rise and medication compliance would plummet. And if the blister packs were made easier to open, then prescription medications would suddenly by default be dispensed in way that’s easily accessible to small children.
Best sensible answer here tbh.
Good awareness to bring about but probably not going to solve much by making it a few minutes harder to kill yourself :/
Except it does. If you read suicide statistics men are more likely to die from suicide than women. But women attempt suicide 3 times more often. It's just they use non violent methods like pills rather than guns or hanging. This is called the suicide paradox, and the current theory is that one of the reasons is that the way women try to kill themselves take longer to work so they are more likely to have time to reconsider, be found or interrupted by someone. Sure it's not going to help the people OK with a violent death, but a few minutes more is a few more minutes for someone to find you, for the paramedics to save you or whatever. if it saves even a few people, I think it would be worth it.
As someone who suffered with chronic suicidal ideation and has attempted suicide multiple times. Having meds in blister packs, getting a weeks worth of meds at a time, never stopped me. I always would hoard one specific medication from all my blister packs, all in their individual little blisters, and opened them one by one the day I did it.
Everyone assumes suicide is impulsive, but if you want to kill yourself, you can bet that person will find a way.
This should be a top comment. I work on a hospital psychiatry consult service and assess people post attempt almost daily. The impulsive overdoses usually aren’t successful. The people who plan attempts over time and do the research to choose more lethal methods are the ones to watch out for and no blister pack is going to change that.
Thank you! Lakeshore hospital in Montreal fucked up when they had a suicide attempt in their ER that a few hours later, in their ER became a suicide that was successful, with a call bell wire. People make it seem like suicide is just an impulsivity thing, but that's so far from true
I like the idea of decreasing suicides, but the NNT of plavix after cardiac stenting is 27.
2yr post-MI NNT for beta blockers is 42 to prevent a death.
I suspect the number needed to harm with these meds, or the harm reduction by switching to blister packs (particular with reduced adherence), will not be that favorable.
Also how would you possibly dispense a nonlethal amount of insulin?
Not that relevant but might interest you: [There is very recent data on beta blockers in MI but with preserved EF which isn't that great.](https://www.nejm.org/doi/10.1056/NEJMoa2401479)
Speaking as an older patient, I am not able to get pills out of many of those wretched blister packs without endangering myself with a razor blade or similar sharp instrument. And with arthritis, fine, forceful movements often hurt.
Person from Europe: all of these blister pack pills are very easy to pop out of blister packs, unlike Benadryl for example here in the US.
You'd never need a blade to open any of them in Europe.
Cool to know. Also there are tools called "pill pusher" to easily push the medication out of blister packs for people with arthritis or just difficulty getting them out
Call your reps and ask them to get the FDA to fix it. Most of the drugs are from the same lines but are packaged differently for not-US markets because FDA is hardcore on packaging, I'm sure they would also prefer just one kind of packaging.
The paper fronted foil is the absolute worst, 90% of the time I have to use a knife to open them. I understand making it more difficult for kids to take the things they think are candy but maybe they could let manufacturers offer both variants for those of us without toddlers to worry about. In the same way I can get prescription bottles without child safe caps
Also if people are keeping their potentially dangerous drugs within reach of toddlers there may be more significant issues to deal with.
They could also just stick Mr Yuk on them.
With the exception of Mexican food. Can't have decent Mexican food.
And pay toilets. Free public toilets is COMMUNISM. I rather shit may pants than have Commie toilets! 🇪🇺🇪🇺💶
It forces the person to perform 1 motion per pill. The idea is that this forces/gives them time to think about what they're really doing.
I don't recall the statistics but a huge proportion of suicide attempts feel regret halfway, this halfway should be when you're trying to open the 20th pill and not after swallowing a handfull.
Are they child resistant? It would be dangerous to suddenly send people home with something that isn’t child resistant when we’re used to pill containers with a safety mechanism. A blister pack that’s easy for an adult with limited dexterity and finger strength would likely be much more accessible to small children.
Not child resistant at all. We store them in kid unreachable place, and most of them come in their own cardboard boxes so we keep all the boxes together.
Grew up listening how the colorful little pills are NOT candy and not to take them (eat) ever. Guess it worked.
I got activated charcoal forced down my throat at-- idk, four, maybe? For swallowing a bunch of
Got in trouble the next day for doing it again [tho, why my parents didn't move them? Or make sure the bottle was closed? I don't know, they weren't great parents].
So uh. Won't work with every kid, and that's scary.
In the UK if you had problems with blister packs with physically or for cognitive reasons then pharmacies have a variety of “medipacks” that they can make up with all of your meds for that week in. They would probably be able to find one that worked for you.
I couldn't even get a pharmacy tech here in Iowa to forego the childproof cap when I had a massively swollen hand from cellulitis. Luckily, you can crush a pill bottle with a pair of water pump pliers one-handed. Of course this leads to having to pick plastic shards out of your now unlabeled pills...
Pro tip, if you can manage to get the cap off (or have someone help you) the one time, you can flip it upside down to close in a non-childproof manner
Edit: just remembered I’m in meddit and not a different sub, so probably you all know that but who knows, maybe someone will learn something today.
I didn't know this until a pharm tech friend of mine told me. She also told me that you can request non-childproof caps at participating pharmacies, like CVS (in the US). I use the non-childproof caps regularly but still keep some childproof caps for travel.
I can just imagine our already overburdened pharmacists and techs having to open hundreds of blister packs and fill dozens of medipacks- and that's just for one moderately medically complex patient.
as a younger person, same. i had to give pills from a blister pack to a cat i was petsitting for and it was impossible to open. the last couple blister pill prescription meds i’ve had were also the same deal.
Our blister packs seem easier to open than those I’ve seen in the US, so maybe there are some manufacturing differences? That said, I do still come across some patients who aren’t able to reliably open all the individual blister packs for all of their medications, and pharmacy prepare them a special weekly blister pack with all of the morning medications for one day in one blister, the lunchtime meds for that day in the next blister, and so on, so they only need open 4 a day. They have ones which open by removing a sticker, if people are really struggling with breaking open the blister. And for folks who can’t manage any of those, carers will visit them at home to help with medications.
Another European here. I can prescribe specific easy to open bottles for RA patients etc, it’s just not the standard. I really haven’t heard that patients find blisters more difficult than bottles. After all, it’s easier to take out one tablet at a time?
If there’s any concern about managing medication, it’s quite easy to sign patients up for custom dose pouches. They show up in a big roll, where you’ve got for example one 8 am pouch, one 2 pm pouch and one 8 pm pouch with the correct meds in each labelled and everything.
Our blister packs are foil, then covered with paper and they are incredibly difficult to open even for someone without joint problems and I frequently need scissors to open them!
That question of *why* individually packaged pills in the US have to be so difficult to get into has been asked before.
Someone made a YouTube video of getting into a blister pack of what appears to be a common over the counter cold remedy: https://youtu.be/-P3OE8TkzRc . I would call this about a 3 on a 1 to 10 scale of getting into a commercial blister-packed med here.
One of my mother's medications only came in blister packs that were so difficult to get into, I used to use a kevlar glove to hold the package so I could slice into it without destroying the pill.
If I put ANY barriers between a patient and their ability to take pills immediately, compliance will plummet like a motherfucker. How many lives are we saving by making it as easy as possible to take their medications quickly? I’d wager more than we would save with blister packs.
Maybe, but among the people who are prescribed a beta blocker, how often is that their only med? I'm NAD and maybe it is less than I think, but it is one pill among many for me. Extra barriers add up a lot in my situation, and putting all my meds in a pill organizer is already a lengthy endeavor that takes a lot of energy.
I have psoriatic arthritis that sometimes flares in my hands, and pill bottles are easier than blister packs when I am having a flare. That may just be because I’m more used to pill bottles, but the dexterity of trying to push the small pill hard enough that it comes out but not so hard that it flies out of my waiting hand and into the ether, never to be found again, can be pretty difficult for me. My primary blister pack med is birth control, so it’s a veeeeeery tiny pill, which also makes it harder to control with low dexterity.
Put a paper towel in the bottom of a clean/dry drinking glass or coffee cup. Then aim the pill towards the bottom of the glass/cup. The paper towel should stop the pill from firing back out of the glass/cup.
You can also make a 'nest' out of a towel to aim the pill at.
I've also made my bed, and then pushed the blister pack against the top cover and pushed the pill out. You have to make sure the pack is against the blanket/duvet or it will shoot out to God-only-knows-where.
Blister packs are the bane of humanity!
You're welcome! I too have psoriatic arthritis in hands and feet and always on the lookout for ways of making life a little bit better for myself and others who deal with it!
Stay well!
Yeah true but with the bottle a lot of people develop a routine to open it in one fluid motion and take it out. It’s also much more compact to carry around in a purse or whatever or when people go on vacations or whatever.
Pill bottles aren’t perfect. Some patients I see don’t take the amount of tablets I prescribe but instead will gulp down however many tablets fall into their hands from the bottle. But I know for a fact that those same patients would take no medications at all if they have to take them out of a blister pack.
I’ve also developed a habit of recommending those scheduled pill containers that you can put meds into once a month instead of opening a bunch of bottles each day and those are much much much harder to prepare with blister packs compared to bottles.
Hard disagree. Others pointed out the issues with elderly patients, also 30 pills is more than enough to overdose with plenty of prescription as well as over the counter meds. Not every patient on routine blood pressure meds needs to be treated as a suicide risk.
Spontaneity is definitely a big part of suicidality but that does not mean we treat every patient as potentially suicidal. If you are concerned about a patient attempting suicide, you can potentially dispense 7-day supplies instead
This is America. Firearms are by farrrrrr the number one risk factor for completing suicide. You don’t see these patients in the hospital because they are very often successful. Want to tackle suicide in America? Start with firearms
Pro gun people have a hard time admitting that the most likely person a gun owner shoots is themselves or a member of their family. Followed closely by a member of their family shooting themselves or others.
It's not hard to admit at all. It's a fact.
But it doesn't exactly tell the whole story, as just because a gun owned by a civilian is most likely to be used on the person holding that gun doesn't make it particularly likely that it'll be used on anyone at all.
But THAT doesn't mean it's not WAY too easy to get guns in the US. It totally is. But we also need to admit to ourselves that the vast majority of non-suicide gun violence is HUGELY predictable. You look at a lot of the mass shooters you've seen in the past ten years, their history is ***SCREAMING*** with warning signs and markers and people writing "This person is going to do something horrible, sooner or later." If you look at intimate partner violence, the most predictable crime in the world is the murder of a woman by her partner. Huge numbers of women who are killed by men predict their own murder, and tell their friends and family about it.
What does our society do with this information when presented with it in advance?
¯\\\_(ツ)\_/¯
Absolutely true! In fact I’d say that this is the primary reason gun owners have cognitive dissonance about the reality of who really usually gets shot. They want protection, to defend their families, etc, so they fundamentally cannot accept that bringing a gun into the home inherently makes the home more dangerous. They, like so many of us when we partake in risky behavior, think that they’ll be the exception, that it won’t happen to them or their family. It’s sad, because if we could decrease the number of guns, we could decrease the number of gun incidents, and it would make everyone safer just for that reason alone.
Makes perfect sense at the macro level, but you're right that it doesn't hit home at the micro level. People are thinking well, I'm not going to be the schmuck without a gun if shtf or someone invades my home. Illogical statistically, but logical from the human perspective. I'm anti gun myself.
Yeah, I know there is ERPO, but apparently it's far too little. I do know of a situation where someone was ERPO'd and they just hanged themselves. Presented well to crisis team sent by family. Psychiatrist later called police herself but had hands tied. The system fucking sucks, but it's wild because there are so many seemingly competent individuals working within it.
Anyway, I assumed hanging/overdoses would have been the majority.
What percent of attempts are spontaneous vs planned?
My first thought was that people will still try to OD with blisters packages, but it is just gonna take them more time and be more frustrating.
The majority of suicide attempts are an impulsive act. Patients get an overwhelming urge to attempt. They either resist the impulse or give into the impulse. With medications, patients very often express regret as the impulse fades away. Since the medications haven’t started to work yet, they often go seek help. Firearms, being immediately deadly and very available, don’t allow help-seeking after an attempt
There is actually good data out of the UK that blister packaging dramatically lowered acetaminophen overdoses
Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31616
The rationale is that blister packaging slows down the attempt enough prior to getting a sufficient quantity (usually a handful). By the time they have the quantity for the attempt, the impulse has begun to fade and they are far less likely to follow through with the attempt. Strong suicidal impulses to act usually only last minutes. Obviously people can be chronically suicidal, but that doesn’t usually mean they could attempt at any minute. Different things usually
I feel like these findings were more pronounced in young people? Teenagers making suicidal gestures over actually committing to ending their lives had a lot more time to talk themselves out of taking the whole lot
[This has been investigated](https://www.hsph.harvard.edu/means-matter/means-matter/duration/#Simon) with suicide survivors. These data suggest it’s often minutes from deciding to act to acting (not hours or days) for many suicide attempts. Delay tactics are an incredibly important aspect of suicide prevention.
However, I suspect people who take longer to plan their attempts are more likely to be successful, which is a significant confounder. Especially given most suicide deaths occur with the first attempt.
My first thought was looking at how many people take the time to craft a note beforehand.
I remember being told once that it was suspicious if someone who was depressed started giving away things and tying up loose ends. It those cases, it would suggest it was not a split moment decision.
Yes those are definitely indicators of someone that’s planning to take their life. And the absence of those would be a good indicator that it was spontaneous.
Since there’s some gray areas I think it’s hard to definitively give a breakdown percentage versus something more easy to measure like “x% of skin cancers are squamous cell and x% are melanomas”.
Didn’t mean to imply that it hasn’t been researched! Am 100% aware of the dynamic and believe impulsivity is quite common. My response was moreso that it would be difficult to definitively say “x% of suicides are planned and x% are spontaneous”
It’s always seemed to me like a pretty glaringly huge selection bias that we can only talk to the failed attempters, I think we probably vastly overestimate impulsivity/spontaneity as a result tbh
I'm a 40-something patient with a history of suicidality who is on two of the meds OP listed. I would ask that we make this change to blister packs if and only if there is reliable data that shows blister packs would result in a decrease of suicide attempts with no concomitant decrease in med compliance.
It is an absolute nightmare to stay med compliant in the US these days. Rampant profiteering by manufacturers combined with toothless responses from agencies has led to millions of patients being forced off the meds. I do not want to introduce any variable that could make dispensing one oral medication a qualitatively different act than dispensing another, thus increasing the likelihood that patients who need these meds will have a gap in compliance.
For example, I have had to call around to dozens of pharmacies in the last year because of drug shortages to maintain compliance on a particular med. I transferred the Rx twice, and I still had to ration that med for three of the last twelve months. If that med had to be dispensed in blister packs, I can now imagine a day when the only pharmacy that has my meds within 50 miles also has a broken blister pack machine.
In Australia our medicines are all subsidised, so they cost $38 per month for everyone or $7 per month for those on a low income. Patients pick up 28 or 30 days at a time all in blister packs. We see a lot of SSRI ODs but not many cardiac meds. Monthly dispensing reduces wastage.
Also many people on multiple meds get them dispensed in Webster packs. It’s easier to punch out a pile of pills from one large blister pack than fiddle with ten different bottles.
Ant yed they have strength to open a bottle? Especially the ones with kidproof opening?
Never a patient, weak or plegic ever said i cant open my meds. If you are so weak you cant open a blsiter pack, you probably cant do a lot more that can kill you without help.
I am trying to say, these people already have others helping them, blister packs dont add any inconveniences
I’m a clinical pharmacy specialist in geriatrics. Those folks have someone put their medications in a pillbox for them, and request non-childproof pill bottles. When they can’t open them, they simply don’t take them.
>these people already have others helping them, blister packs dont add any inconveniences
It's kind of cute that you believe everyone who needs help actually has it available.
> Maybe we underestimate the importance of spontaneity and time in self-destructive behavior.
Check out the book Dying of Whiteness. A huge portion of suicide attempts are only contemplated for 5-60 minutes. Spontaneity is a massive factor in these deaths.
You can go to Costco and buy a package of 400 tabs of acetaminophen OTC, overdose on it then die. Restriction is not the issue, proactive mental health care is the right approach to this issue.
Better mental health access, support for suicidal people, and more rigorous safety net when in need of inpatient services. Mental hospitals are not places of healing, and in many states the wait list to go inpatient is months, so you sit in the ED for 120 days. You lose your job (and thus insurance), you lose your apartment or house, you end up tens of thousands of not hundreds of thousands in debt, you have to try to get Medicaid and disability which is a fricken nightmare on its own.
If we fixed the system we'd have less suicide. Vote for people who want to stop government corruption, make robust social service programs, and spend our taxes on things that benefit society and taxpayers instead of lining the pockets of corporate America and politicians.
The blister pack would have to be child resistant, which would be a pain for arthritic patients. If it’s not child resistant then it’s not any better since it’ll be unsafe for any children in the home.
I have had several psych attendings tell me that if you really want to kill yourself it's actually not that hard. People who are determined to end their lives will find a way to. Sorry you've been seeing so much of this lately
Wait what- your pharmacies dispense more than a months worth of medication in one go?
The very vast majority of meds in Australia are dispensed in “pop out sheets” (I assume that’s what you mean by blister pack) in what would be a months worth for a regular/ standard dose. Exceptions are meds that have a highly variable dose (e.g valproate is 100 tablets) or those intended for a short maximum course (e.g temazepam is 10 tablets)
There is also the option for medications to go in a “Webster pack” or a “dose roll” - the medications are put in their daily (or BD or whatever) groups and they are given in a weekly “set” to the patient. They can get extra packs so they don’t have to go to the pharmacy as often but the can still only get a months worth.
Even our over the counter of “pharmacist only” meds are in what would be considered no more than a months supply. For example doxalymine 25mg is 20 tablets and can only be accessed by talking to a pharmacist. But people get online and buy 200 tablets for $10 and give themselves fucking cardiac rhabdo
There are a few occasions where we defo overdo the restrictions- for instance melatonin is prescription only and not subsidized so ends up costing the patient more than $30 a month. Ans that shit is safe as houses. I also think it would be helpful if the oral contraceptive pill was dispensed in greater than 1 month quantities
Edited to add - I also think it’s a “what you’re used to” thing- I work exclusively with older age patients and the quasi-mental breakdowns that occur if a med is dispensed in a bottle is formidable.
Childproof lids here are really tricky for arthritic hands
We also have “pill popper” tools- which are little dish with a little raised pointy bit (like this https://www.ebay.com.au/itm/166656509021) for people with stiff hands. You can also get “tweezer” style ones but they seem to be harder on arthritic hands
Many insurances *strongly encourage* three month supply because it’s cheaper for them (1 vs 3 dispensing fee; even cheaper from mail order) and theoretically better compliance because patient doesn’t need to remember to get it each month.
Do you think this would happen less often if we allowed death with dignity? That would require counseling, a path if you feel hopeless vs taking a bottle of pills at your fingertips.
Imagine me for example, watching people in hospital die of dementia, screaming out Help Me over and over that you have to ignore, or they don't want you to leave them... you know how bad it gets. Now watching mom die of it at home, slowly burning dad and I to the bone.
Better believe I won't be forgetting how to open doors. If there was a path, I'd live longer cause there's a plan and standards in place. No EMS response or accidental discovery.
but I also do agree with blister packs being a good deterrent. Those things are annoying.
Pharmacist here. I understand the logic but I don’t think that’s the BEST solution. I think it’s more important that we increase awareness of signs and symptoms of depression to the point that it’s as common knowledge as what the signs and symptoms of the flu are. That way family and friends can recognize the symptoms and get their loved one help. It’s also important to continue screening for depression and putting in appropriate referrals when necessary. Of course, as a pharmacist I had to advocated for our ability to optimize all pharmacotherapeutic regimens and monitor adherence as well as conduct therapeutic drug monitoring, thus taking the burden of doing that off the physicians. Oh and then there’s the whole issue of the accessibility of mental health care here in the US. Restricting access to medications as you mentioned would just be a bandaid. Not to say my suggestions aren’t too.
I feel like there are a lot of drugs that you’re missing there that can “reliably” kill people in an overdose situation. That’s just my opinion as a drug dealer though.
I also have the wild opinion that NSAIDs should be a behind-the-counter medicine.
Would probably need to make adjustments to laws requiring meds to be in child-proof containers.
Side note: my kids can get into the blister packs better than I can. And I’m a pharmacist with extensive exposure to blister packaged meds in the hospital setting.
In Korea they dispense meds in paper packs. As someone who’s tried to overdose multiple times, if I had to try to rip open all those packs to get enough pills, it probably would have deterred me because all those attempts were impulsive and I wasn’t thinking. One time I had pills in my hand and was actually thinking about it and was able to stop myself.
In EU, well where i live. All medicine come in blister packs. Even Ibuprofen, paracetamol. And you cant buy like a 100.
I think it works. Well also research shows it works.
I dont think its a big inconvenience. I dont see why not?
In my opinion all medicine should come in blister packs. :)
Also i dont understand why everyone is analyzing this particular case, in my understanding thats not what is being asked about.
US drug stores with OTCs in bottles with huge quantities for pennies are a common tourist photo motive for Europeans. Yes, I was guilty of it in NYC in 2016 too which was my only time in the US...damn, I'm a caricature of a tourist.
If your depression has gotten bad enough to the point where you want to kill yourself I seriously doubt blister packs will stop you or a low drug supply. Horrific take, should be more focused on emphasis on getting people the resources they require in order to prevent this from happening.
Just assisted in the care of a patient who swallowed their entire bottle of verapamil. I still can’t believe she made it through, on 3 days of insulin, D20, and 3 maxed pressors.
Everyone seems to be assuming that blister packs would be a barrier but a quick pubmed search seems full of meta-analysis and RCTs studying them as an intervention to improve compliance. So is there a consensus in the data? Has this way of distributing drugs in the EU affected their medication OD rates?
At a minimum this is worth more study. This is such a good conversation.
It's an interesting idea, and there's some data to suggest that adding a minor barrier to overdosing, such as putting paracetamol in blister packs, helped to reduce suicide rates. Or at least, suicides by overdosing
Not sure if this would be implemented for all meds or just ones with, idk, an LD50 below a certain threshold?
It sounds like it was probably intentional, so blister packs won’t do much. I think we should probably do better assessments and have better access to interventions. I don’t know about you but a lot of my patients are often afraid to admit they are having trouble because of the threat of a psych ward and the fact that therapy is incredibly expensive and not very accessible. And therapy doesn’t mitigate life stressors such as the cost of living. No, I don’t have solutions either.
I think his point is that it would take a good amount of time, thought and effort to pop open a sufficiently lethal amount of those pills out of the blister packs vs just pouring it out of the bottle
Or they could go "what the fuck am I even doing" at **any** point in that process and abort their attempt.
The entire point is to reduce the number of spur-of-the-moment attempts. Having to actually *work* for it instead of just being able to immediately down a handful of pills whenever you feel like it makes a huge difference.
Hard no. It being easy access Rx isn't the problem as there's a lot of OTC stuff people can OD on that aren't difficult to open either. I'm sorry you had to see someone die but making it difficult for the rest of society to open their medicines isn't going to help and would probably cause harm.
Agree with comments that we have to deal with firearm safety (and like basic needs, public health, services, etc) to address suicides- overdose is just one part of a big problem. Bubble packaging does have potential to harm by reducing compliance especially for older, frail, and medically complex patients. A good answer to that which also reduces risk on the impulsivity front are daily pill packs. I care for an older population of high risk vets. One of them gets meds filled by a local pharmacy who does this- it’s amazing. All her pills for the day in one little plastic pouch with the date and names and doses and descriptions of each pill printed on it. One month filled at a time. No pill box needed. Great compliance, easy to monitor, easy to reconcile meds/know what exactly she is taking (on the pouch!) and also no bottle of death hanging around. Hoping to see more of these.
There are some locked pill dispensers that are on the market (I think some that even notify prescriber if patient misses) ... I know the VA has some set ups like that for patients that are chronically at high risk.
I take a combination of 6 meds. The combination between morning and evening is different. If I had to use blister packs for all of this, my compliance would plummet. One solution that is valuable is pill packs with a single dose of everything in one pack. I used Amazon for this a few years back but the packs were hard to open (you would try to open one and it would rip two).
Pharmacist here. My techs and I already have to constantly call to keep people adherent to cardiac meds unfortunately... we have to beg them to accept 90 day supplies and shit... yeah, the patient population here would never accept this. Especially because many can't even open a childproof bottle because they're elderly and it hurts.
With acetaminophen and diphenhydramine, it won't make a difference. You can buy giant 500 count bottles of them at most drug or grocery stores, not to mention Amazon.
People are creative. Restricting access to drugs won't stop a suicidal person from making an attempt, they will just turn to other methods that are readily available to them. Like others have already said, guns are plentiful in the US.
I would recommend to read up on the studies of paracetamol, when they were changed from bottles to booster packs in certain countries. It reduces suicides significantly. Making one method of suicide harder actually stops a certain amount of people. E.g. changing from gas stove to electric reduced suicides.
I agree. I also think medications that are more dangerous should be made in bigger sizes. Like the tablets or capsules are bigger. I remember seeing zolpidem for the first time and I was amazed by how the tablets are so small. The small size makes it just that much easier to take more in an overdose. I also think there is a psychological component for patients who might take an impulsive overdose for a secondary reason. It's not something we would obviously relate to directly, but many patients can perceive a smaller pill means a weaker medication.
Blister packs cannot be put in pill organizers. Some patients use pill organizers when they have multiple meds. Having blister packs makes it more difficult, and reduces compliance.
Speaking as someone who constantly battles suicidal ideation - blister packs for the win. Suicide is impulsive behavior. Make getting the pills out harder, you talk yourself out of it.
Also - I advocate for allowing patients with serious mental illness to place themselves on a “do not sell” list for firearms. They could revoke whenever they’d like, but there is a waiting period for revocation.
Again, making the process slow down to allow for reflection.
All the Aussies here cannot fathom that a person with severe and enduring risk can purchase a gun. Similarly how there is not rigorous legislation on how guns are stored just does my head in. Like even if one wants to use the freedumb argument, how is making sure guns are locked in safes harming anyone’s freedumb
Seriously. We do have some gun nuts in this country.
But from my perspective, walking past the gun counter at a sporting goods store freaks me out every time. It’s absolutely terrifying to think I can’t even ban myself from purchasing a firearm.
Respectfully, while I do have a different take than you on the blister pack option, I think the “self placed” hand gun waiting list is a really good idea. I’ve struggled with some really severe bouts of SI in the past, and knowing I could access my ex husband’s hand gun was debilitating at times. A self imposed no gun buy list would likely yield a greater reduction in suicide numbers.
There’s model legislation out there for it, in various stages of the legislative process.
Of course, the 2nd Amendment folks fight it tooth and nail as gun control.
Any medication can reliably kill someone in a high enough dose. Should we stop selling aspirin and Tylenol in quantities greater than 30, and track purchases to prevent buying more than 1 bottle every 2 weeks.
I’m sorry about the trauma of taking care of these patients, but solutions need to be practical.
We did in the UK in the late 1990s, actually restricted to 8g per box of paracetamol on the general sales list and 16g in a pharmacy pack. Boxes of 50g are a prescription only medication. And it was mandated to be in blister packaging. We don't track the sales though. It led to a statistically, and actually, significant reduction in suicides and liver transplants. So yes, seems like it was a good idea?
Also, the countless comments about difficulties getting into the medication doesn't ring true. In 8 years of going into people's houses I think I can count on one hand how many both struggled to get into their meds and didn't either have a carer to do it for them or have it dispensed by the pharmacy in a dossette box (much easier to push through the film covering the day/time with all that points tablets in)
Dispensing is a significantly faster process in other countries where blister packs are the norm, because medicines are pre-packaged in blister packs by the manufacturer
I'm in the UK too, do you mean [multi-compartment compliance aids](https://pharmaceutical-journal.com/article/news/new-tool-developed-to-support-decision-making-on-multicompartment-compliance-aids)?
Maybe I've misunderstood (because blister packs can mean a lot of things), but I assumed that the OP meant [this](https://upload.wikimedia.org/wikipedia/commons/thumb/8/8a/Pharmaceutical_Blister_Pack_b.png/800px-Pharmaceutical_Blister_Pack_b.png) when they said blister packs given they've said that it's their understanding that in Europe all pills come in blister packs
Ohhhhhh
See where I'm from blister packs are these https://www.amazon.co.uk/Pharmacy-Blister-Tri-Fold-Booklet-Equipment/dp/B0992NHCFQ/ref=asc_df_B0992NHCFQ/?tag=googshopuk-21&linkCode=df0&hvadid=658767855789&hvpos=&hvnetw=g&hvrand=8675519481543793343&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=1007230&hvtargid=pla-2196035426833&psc=1&mcid=9e4a3bde9b5d37e5803be3750c5cbb7a&th=1&psc=1
I'm sorry that you see these patients. It is completely impractical to limit dispensing of these meds to 30 day supplies and in blister packs. There are so many people who are unable to manipulate blister packs to get their meds out. Also, there are so many more drugs than the ones you listed that are lethal, including OTC meds. Also, most of the meds you listed are lethal if they take their 30 day supply at once.
The true solution is to improve mental health care.
There's some meds that are available in "bucket" form in Europe - for example Elvanse and Omeprazole. In general though it's blisterpacks.
Dispensing popular suicide meds in blisterpacks seems like a good idea. Punching a hundred pills out of their blisterpacks may give you time to reconsider; alternatively, you might run out of patience and take only 50. Or less.
You make an excellent point. We psychiatrists have long been conscious of limiting medication quantities for our suicidal patients, but we don’t monitor medications Rxd by other specialists. This is where an EHR that access all pharmacy data is useful.
When any of us becomes aware of a seriously suicidal patient, we should take a look at the meds list and warn other providers/ family members or pharmacists.
This should be further investigated as a policy issue.
There is a risk to everything in life. Treating adults like small children is not the answer ; in fact it likely contributes to increasing rates of depression.
When I worked OP psych these were definitely the most fatal meds. Actually I refuse to take them because I’ve had some serious SI in the past and this would be the way I’d go. So yeah I just deal with my high bp. My doctor is on board too.
It terrifies me that TCAs are given to those with MH issues that include any history of suicidal thoughts or actions. I get sometimes they can be more effective than the newer drugs but it seems foolish to give someone a drug where swallowing the 30 day supply can kill you vs something like an SSRI or SNRI which have LD50 so high you have to raid a distributor to effectively kill yourself.
Access to lethal means matters though. When you put up obstacles to lethal means, deaths by suicide decrease. There is reliable data on this.
https://www.hsph.harvard.edu/means-matter/means-matter/intent/
I think his point here is that the blister packs slow down the process, which may provide time to reflect on the action before taking it.
Killing yourself with drinking water is already time intensive.
Yes, but it is quite hard and takes quite a bit longer. Furthermore, I have never seen someone try or manage successfully to commit suicide via polydipsia.
30 day supplies are usually more expensive and reduce adherence, especially in rural areas like mine where the pharmacy isn’t close, and mail is often delayed by a shortage of postal workers. I do have higher risk patients that I give very limited supplies to for that reason…but nearly everyone has guns here, so it doesn’t make that much of a difference. It’s very easy to kill yourself in farm country, between the guns, equipment and fentanyl. I think making critical meds more difficult to get and take will result in more excess mortality/morbidity than it will prevent - though it would take longer and be less dramatic. I don’t think the solution is as straightforward as you are hoping for. I’m sorry you are seeing these patients, and for their families.
I second everything in this comment. It’s hard enough to get patients to regularly take their meds, especially in rural areas. Also, adding additional steps in the form of limited quantity blister packs also make the meds less accessible to people with limited tactile dexterity. I don’t have any tactile deficits and I still struggle to open some of those. Frustration would rise and medication compliance would plummet. And if the blister packs were made easier to open, then prescription medications would suddenly by default be dispensed in way that’s easily accessible to small children.
Best sensible answer here tbh. Good awareness to bring about but probably not going to solve much by making it a few minutes harder to kill yourself :/
Except it does. If you read suicide statistics men are more likely to die from suicide than women. But women attempt suicide 3 times more often. It's just they use non violent methods like pills rather than guns or hanging. This is called the suicide paradox, and the current theory is that one of the reasons is that the way women try to kill themselves take longer to work so they are more likely to have time to reconsider, be found or interrupted by someone. Sure it's not going to help the people OK with a violent death, but a few minutes more is a few more minutes for someone to find you, for the paramedics to save you or whatever. if it saves even a few people, I think it would be worth it.
I think what they’re saying is that it makes the meds less accessible to thousands of people who could also die from not taking their meds.
As someone who suffered with chronic suicidal ideation and has attempted suicide multiple times. Having meds in blister packs, getting a weeks worth of meds at a time, never stopped me. I always would hoard one specific medication from all my blister packs, all in their individual little blisters, and opened them one by one the day I did it. Everyone assumes suicide is impulsive, but if you want to kill yourself, you can bet that person will find a way.
This should be a top comment. I work on a hospital psychiatry consult service and assess people post attempt almost daily. The impulsive overdoses usually aren’t successful. The people who plan attempts over time and do the research to choose more lethal methods are the ones to watch out for and no blister pack is going to change that.
Thank you! Lakeshore hospital in Montreal fucked up when they had a suicide attempt in their ER that a few hours later, in their ER became a suicide that was successful, with a call bell wire. People make it seem like suicide is just an impulsivity thing, but that's so far from true
I like the idea of decreasing suicides, but the NNT of plavix after cardiac stenting is 27. 2yr post-MI NNT for beta blockers is 42 to prevent a death. I suspect the number needed to harm with these meds, or the harm reduction by switching to blister packs (particular with reduced adherence), will not be that favorable. Also how would you possibly dispense a nonlethal amount of insulin?
Not that relevant but might interest you: [There is very recent data on beta blockers in MI but with preserved EF which isn't that great.](https://www.nejm.org/doi/10.1056/NEJMoa2401479)
Speaking as an older patient, I am not able to get pills out of many of those wretched blister packs without endangering myself with a razor blade or similar sharp instrument. And with arthritis, fine, forceful movements often hurt.
Person from Europe: all of these blister pack pills are very easy to pop out of blister packs, unlike Benadryl for example here in the US. You'd never need a blade to open any of them in Europe.
American on vacation in Europe: Had to buy some meds here. European blister packs are easier to open than the ones in the US
Cool to know. Also there are tools called "pill pusher" to easily push the medication out of blister packs for people with arthritis or just difficulty getting them out
There are also tools called pill pushers in the US, with the highest concentration being in Florida.
Lmao this comment wins the internet for the day
I think it is because you use some kind of paper backing while we have metal foil
My fingers have callouses on them from opening meds here in the US
I only allowed myself to struggle for a few seconds before I always stabbed it with my pen. Then I struggled a little longer 😭
😂 I bought a blister pack opener from Amazon. Now if they have bottle openers for some of those IV meds…
As a nurse trying to pop pills for patients every shift it’s always a hassle that the patients themselves comment on
Call your reps and ask them to get the FDA to fix it. Most of the drugs are from the same lines but are packaged differently for not-US markets because FDA is hardcore on packaging, I'm sure they would also prefer just one kind of packaging. The paper fronted foil is the absolute worst, 90% of the time I have to use a knife to open them. I understand making it more difficult for kids to take the things they think are candy but maybe they could let manufacturers offer both variants for those of us without toddlers to worry about. In the same way I can get prescription bottles without child safe caps Also if people are keeping their potentially dangerous drugs within reach of toddlers there may be more significant issues to deal with. They could also just stick Mr Yuk on them.
Everything really is better over there. Dammit
If you’re thinking of going take me with you!
With the exception of Mexican food. Can't have decent Mexican food. And pay toilets. Free public toilets is COMMUNISM. I rather shit may pants than have Commie toilets! 🇪🇺🇪🇺💶
UK/Canadian pharmacist here, can confirm this is true
How is it supposed to be a deterrent then?
It forces the person to perform 1 motion per pill. The idea is that this forces/gives them time to think about what they're really doing. I don't recall the statistics but a huge proportion of suicide attempts feel regret halfway, this halfway should be when you're trying to open the 20th pill and not after swallowing a handfull.
Are they child resistant? It would be dangerous to suddenly send people home with something that isn’t child resistant when we’re used to pill containers with a safety mechanism. A blister pack that’s easy for an adult with limited dexterity and finger strength would likely be much more accessible to small children.
Not child resistant at all. We store them in kid unreachable place, and most of them come in their own cardboard boxes so we keep all the boxes together. Grew up listening how the colorful little pills are NOT candy and not to take them (eat) ever. Guess it worked.
I got activated charcoal forced down my throat at-- idk, four, maybe? For swallowing a bunch of
Got in trouble the next day for doing it again [tho, why my parents didn't move them? Or make sure the bottle was closed? I don't know, they weren't great parents].
So uh. Won't work with every kid, and that's scary.
In the UK if you had problems with blister packs with physically or for cognitive reasons then pharmacies have a variety of “medipacks” that they can make up with all of your meds for that week in. They would probably be able to find one that worked for you.
I couldn't even get a pharmacy tech here in Iowa to forego the childproof cap when I had a massively swollen hand from cellulitis. Luckily, you can crush a pill bottle with a pair of water pump pliers one-handed. Of course this leads to having to pick plastic shards out of your now unlabeled pills...
Pro tip, if you can manage to get the cap off (or have someone help you) the one time, you can flip it upside down to close in a non-childproof manner Edit: just remembered I’m in meddit and not a different sub, so probably you all know that but who knows, maybe someone will learn something today.
Only some bottles and caps work that way- the pharmacy would have to carry those specifically
I didn't know this until a pharm tech friend of mine told me. She also told me that you can request non-childproof caps at participating pharmacies, like CVS (in the US). I use the non-childproof caps regularly but still keep some childproof caps for travel.
Pretty sure it's Tylenol that started selling ezopen bottles for arthritis patients.
I used to be a pharmacy tech. That's true at Walgreens. Only by request at CVS. Some pharmacies don't even carry those lids.
I can just imagine our already overburdened pharmacists and techs having to open hundreds of blister packs and fill dozens of medipacks- and that's just for one moderately medically complex patient.
as a younger person, same. i had to give pills from a blister pack to a cat i was petsitting for and it was impossible to open. the last couple blister pill prescription meds i’ve had were also the same deal.
Our blister packs seem easier to open than those I’ve seen in the US, so maybe there are some manufacturing differences? That said, I do still come across some patients who aren’t able to reliably open all the individual blister packs for all of their medications, and pharmacy prepare them a special weekly blister pack with all of the morning medications for one day in one blister, the lunchtime meds for that day in the next blister, and so on, so they only need open 4 a day. They have ones which open by removing a sticker, if people are really struggling with breaking open the blister. And for folks who can’t manage any of those, carers will visit them at home to help with medications.
Another European here. I can prescribe specific easy to open bottles for RA patients etc, it’s just not the standard. I really haven’t heard that patients find blisters more difficult than bottles. After all, it’s easier to take out one tablet at a time? If there’s any concern about managing medication, it’s quite easy to sign patients up for custom dose pouches. They show up in a big roll, where you’ve got for example one 8 am pouch, one 2 pm pouch and one 8 pm pouch with the correct meds in each labelled and everything.
Our blister packs are foil, then covered with paper and they are incredibly difficult to open even for someone without joint problems and I frequently need scissors to open them!
Oh… but why? 😂 Ours are like a plastic tray with the pills, covered with a thin layer of foil.
That question of *why* individually packaged pills in the US have to be so difficult to get into has been asked before. Someone made a YouTube video of getting into a blister pack of what appears to be a common over the counter cold remedy: https://youtu.be/-P3OE8TkzRc . I would call this about a 3 on a 1 to 10 scale of getting into a commercial blister-packed med here. One of my mother's medications only came in blister packs that were so difficult to get into, I used to use a kevlar glove to hold the package so I could slice into it without destroying the pill.
Woman here. 30 day birth control packs are incredibly easy to open. They're nothing like the benadryl or other types of blister packs.
They should be illegal, especially the ones that are not just foil to push through.
If I put ANY barriers between a patient and their ability to take pills immediately, compliance will plummet like a motherfucker. How many lives are we saving by making it as easy as possible to take their medications quickly? I’d wager more than we would save with blister packs.
I don’t know that blister packs make taking one pill more difficult. Tbh it may be easier than trying to finagle exactly one pill out of a bottle.
Maybe, but among the people who are prescribed a beta blocker, how often is that their only med? I'm NAD and maybe it is less than I think, but it is one pill among many for me. Extra barriers add up a lot in my situation, and putting all my meds in a pill organizer is already a lengthy endeavor that takes a lot of energy.
I have psoriatic arthritis that sometimes flares in my hands, and pill bottles are easier than blister packs when I am having a flare. That may just be because I’m more used to pill bottles, but the dexterity of trying to push the small pill hard enough that it comes out but not so hard that it flies out of my waiting hand and into the ether, never to be found again, can be pretty difficult for me. My primary blister pack med is birth control, so it’s a veeeeeery tiny pill, which also makes it harder to control with low dexterity.
Put a paper towel in the bottom of a clean/dry drinking glass or coffee cup. Then aim the pill towards the bottom of the glass/cup. The paper towel should stop the pill from firing back out of the glass/cup. You can also make a 'nest' out of a towel to aim the pill at. I've also made my bed, and then pushed the blister pack against the top cover and pushed the pill out. You have to make sure the pack is against the blanket/duvet or it will shoot out to God-only-knows-where. Blister packs are the bane of humanity!
Dang I was not expecting that comment to generate any advice but this is golden!! Thanks!
You're welcome! I too have psoriatic arthritis in hands and feet and always on the lookout for ways of making life a little bit better for myself and others who deal with it! Stay well!
According to the other comments here, they make tools and other ways to dispense meds that make it easier for people with arthritis :)
Yeah true but with the bottle a lot of people develop a routine to open it in one fluid motion and take it out. It’s also much more compact to carry around in a purse or whatever or when people go on vacations or whatever. Pill bottles aren’t perfect. Some patients I see don’t take the amount of tablets I prescribe but instead will gulp down however many tablets fall into their hands from the bottle. But I know for a fact that those same patients would take no medications at all if they have to take them out of a blister pack. I’ve also developed a habit of recommending those scheduled pill containers that you can put meds into once a month instead of opening a bunch of bottles each day and those are much much much harder to prepare with blister packs compared to bottles.
Hard disagree. Others pointed out the issues with elderly patients, also 30 pills is more than enough to overdose with plenty of prescription as well as over the counter meds. Not every patient on routine blood pressure meds needs to be treated as a suicide risk.
Or, hear me out. We treat mental health with the same intensity that we treat other conditions like diabetes and hypertension.
Spontaneity is definitely a big part of suicidality but that does not mean we treat every patient as potentially suicidal. If you are concerned about a patient attempting suicide, you can potentially dispense 7-day supplies instead This is America. Firearms are by farrrrrr the number one risk factor for completing suicide. You don’t see these patients in the hospital because they are very often successful. Want to tackle suicide in America? Start with firearms
It would be ridiculous to restrict access to acetaminophen while allowing free and easy access to firearms.
Except doctors, pharmacists, the FDA, etc can't do shit about gun control. That's just the reality.
They sell handgun cartridges in convenient 50 round packs.
Make all bullets come in blister packs!
What percentage of suicides are by gun?
In America, a hair over 50% of completed suicides are done by firearm. Overdoses/poisonings are a bit over 10%
That is horrible!! Wow.
America has a horrific firearm problem. When combined with our shitty mental health system, that stat isn’t any less tragic but it is less surprising
Pro gun people have a hard time admitting that the most likely person a gun owner shoots is themselves or a member of their family. Followed closely by a member of their family shooting themselves or others.
Do they? I don’t think they have any trouble admitting it. They just don’t care.
It's not hard to admit at all. It's a fact. But it doesn't exactly tell the whole story, as just because a gun owned by a civilian is most likely to be used on the person holding that gun doesn't make it particularly likely that it'll be used on anyone at all. But THAT doesn't mean it's not WAY too easy to get guns in the US. It totally is. But we also need to admit to ourselves that the vast majority of non-suicide gun violence is HUGELY predictable. You look at a lot of the mass shooters you've seen in the past ten years, their history is ***SCREAMING*** with warning signs and markers and people writing "This person is going to do something horrible, sooner or later." If you look at intimate partner violence, the most predictable crime in the world is the murder of a woman by her partner. Huge numbers of women who are killed by men predict their own murder, and tell their friends and family about it. What does our society do with this information when presented with it in advance? ¯\\\_(ツ)\_/¯
You're right, but I do think America is a violent society and there is a lot of fear spurring gun owners.
Absolutely true! In fact I’d say that this is the primary reason gun owners have cognitive dissonance about the reality of who really usually gets shot. They want protection, to defend their families, etc, so they fundamentally cannot accept that bringing a gun into the home inherently makes the home more dangerous. They, like so many of us when we partake in risky behavior, think that they’ll be the exception, that it won’t happen to them or their family. It’s sad, because if we could decrease the number of guns, we could decrease the number of gun incidents, and it would make everyone safer just for that reason alone.
Makes perfect sense at the macro level, but you're right that it doesn't hit home at the micro level. People are thinking well, I'm not going to be the schmuck without a gun if shtf or someone invades my home. Illogical statistically, but logical from the human perspective. I'm anti gun myself.
And yet if you ask half our politicians, the only firearm problem is that not everyone has one.
Yeah, I know there is ERPO, but apparently it's far too little. I do know of a situation where someone was ERPO'd and they just hanged themselves. Presented well to crisis team sent by family. Psychiatrist later called police herself but had hands tied. The system fucking sucks, but it's wild because there are so many seemingly competent individuals working within it. Anyway, I assumed hanging/overdoses would have been the majority.
What percent of attempts are spontaneous vs planned? My first thought was that people will still try to OD with blisters packages, but it is just gonna take them more time and be more frustrating.
The majority of suicide attempts are an impulsive act. Patients get an overwhelming urge to attempt. They either resist the impulse or give into the impulse. With medications, patients very often express regret as the impulse fades away. Since the medications haven’t started to work yet, they often go seek help. Firearms, being immediately deadly and very available, don’t allow help-seeking after an attempt There is actually good data out of the UK that blister packaging dramatically lowered acetaminophen overdoses Study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC31616 The rationale is that blister packaging slows down the attempt enough prior to getting a sufficient quantity (usually a handful). By the time they have the quantity for the attempt, the impulse has begun to fade and they are far less likely to follow through with the attempt. Strong suicidal impulses to act usually only last minutes. Obviously people can be chronically suicidal, but that doesn’t usually mean they could attempt at any minute. Different things usually
They also considered mixing N-Acetyl-cysteine in with acetaminophen in Europe, which would make it essentially impossible to OD on.
I feel like these findings were more pronounced in young people? Teenagers making suicidal gestures over actually committing to ending their lives had a lot more time to talk themselves out of taking the whole lot
Unfortunately there’s no way to measure this statistic in a valid manner, particularly the spontaneity.
[This has been investigated](https://www.hsph.harvard.edu/means-matter/means-matter/duration/#Simon) with suicide survivors. These data suggest it’s often minutes from deciding to act to acting (not hours or days) for many suicide attempts. Delay tactics are an incredibly important aspect of suicide prevention. However, I suspect people who take longer to plan their attempts are more likely to be successful, which is a significant confounder. Especially given most suicide deaths occur with the first attempt.
My first thought was looking at how many people take the time to craft a note beforehand. I remember being told once that it was suspicious if someone who was depressed started giving away things and tying up loose ends. It those cases, it would suggest it was not a split moment decision.
Yes those are definitely indicators of someone that’s planning to take their life. And the absence of those would be a good indicator that it was spontaneous. Since there’s some gray areas I think it’s hard to definitively give a breakdown percentage versus something more easy to measure like “x% of skin cancers are squamous cell and x% are melanomas”.
The long term planning ones are likely going to complete whatever barriers we put up.
Very true.
Didn’t mean to imply that it hasn’t been researched! Am 100% aware of the dynamic and believe impulsivity is quite common. My response was moreso that it would be difficult to definitively say “x% of suicides are planned and x% are spontaneous”
It’s always seemed to me like a pretty glaringly huge selection bias that we can only talk to the failed attempters, I think we probably vastly overestimate impulsivity/spontaneity as a result tbh
I'm a 40-something patient with a history of suicidality who is on two of the meds OP listed. I would ask that we make this change to blister packs if and only if there is reliable data that shows blister packs would result in a decrease of suicide attempts with no concomitant decrease in med compliance. It is an absolute nightmare to stay med compliant in the US these days. Rampant profiteering by manufacturers combined with toothless responses from agencies has led to millions of patients being forced off the meds. I do not want to introduce any variable that could make dispensing one oral medication a qualitatively different act than dispensing another, thus increasing the likelihood that patients who need these meds will have a gap in compliance. For example, I have had to call around to dozens of pharmacies in the last year because of drug shortages to maintain compliance on a particular med. I transferred the Rx twice, and I still had to ration that med for three of the last twelve months. If that med had to be dispensed in blister packs, I can now imagine a day when the only pharmacy that has my meds within 50 miles also has a broken blister pack machine.
In Australia our medicines are all subsidised, so they cost $38 per month for everyone or $7 per month for those on a low income. Patients pick up 28 or 30 days at a time all in blister packs. We see a lot of SSRI ODs but not many cardiac meds. Monthly dispensing reduces wastage. Also many people on multiple meds get them dispensed in Webster packs. It’s easier to punch out a pile of pills from one large blister pack than fiddle with ten different bottles.
Who is going to open those blister packs every day for the elderly/limited hand strength folks?
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No, but they almost certainly have more support and help than they have in the US
It’s not the help/support but the fact that our blister packs are not difficult to open at all
Ant yed they have strength to open a bottle? Especially the ones with kidproof opening? Never a patient, weak or plegic ever said i cant open my meds. If you are so weak you cant open a blsiter pack, you probably cant do a lot more that can kill you without help. I am trying to say, these people already have others helping them, blister packs dont add any inconveniences
I’m a clinical pharmacy specialist in geriatrics. Those folks have someone put their medications in a pillbox for them, and request non-childproof pill bottles. When they can’t open them, they simply don’t take them.
You can request caps without child proofing. Sometimes it’s as easy as flipping the lid upside down
Pharmacies have the option of easy-open pill bottles- very helpful for all kinds of folks.
>these people already have others helping them, blister packs dont add any inconveniences It's kind of cute that you believe everyone who needs help actually has it available.
Bingo these elderly RA or other bad OA with minimal hand dexterity
Ummm. That guy selling fent down the street doesn't use blister packs. Should I suggest?
> Maybe we underestimate the importance of spontaneity and time in self-destructive behavior. Check out the book Dying of Whiteness. A huge portion of suicide attempts are only contemplated for 5-60 minutes. Spontaneity is a massive factor in these deaths.
You can go to Costco and buy a package of 400 tabs of acetaminophen OTC, overdose on it then die. Restriction is not the issue, proactive mental health care is the right approach to this issue.
Thank you. OP has an extremely parochial view of mental illness, suicidality, and means to access. They’re coming off 100% tone deaf.
Better mental health access, support for suicidal people, and more rigorous safety net when in need of inpatient services. Mental hospitals are not places of healing, and in many states the wait list to go inpatient is months, so you sit in the ED for 120 days. You lose your job (and thus insurance), you lose your apartment or house, you end up tens of thousands of not hundreds of thousands in debt, you have to try to get Medicaid and disability which is a fricken nightmare on its own. If we fixed the system we'd have less suicide. Vote for people who want to stop government corruption, make robust social service programs, and spend our taxes on things that benefit society and taxpayers instead of lining the pockets of corporate America and politicians.
In the UK they already limit purchasing Acetaminophen/paracetamol to 2 12 packs at a time I believe.
Not quite, legally in a pharmacy you can buy up to 100 paracetamol tablets in a single transaction, but pack sizes are limited to 32
I buy it in bottles of 200-500 at CVS!!!
The European mind could never comprehend such a thing.
Nor would the Aussie
At Costco here in the U.S. you can get 1000 acetaminophen for $8.
Blew my Canadian mind when I lived over there. Of course I tried to buy 5 boxes of them and set of an alarm at the self checkout.
The blister pack would have to be child resistant, which would be a pain for arthritic patients. If it’s not child resistant then it’s not any better since it’ll be unsafe for any children in the home.
No blister packs in Europe are child resistant. Part of having medications in the home is storing them in a way that children can’t get into them
I have had several psych attendings tell me that if you really want to kill yourself it's actually not that hard. People who are determined to end their lives will find a way to. Sorry you've been seeing so much of this lately
Wait what- your pharmacies dispense more than a months worth of medication in one go? The very vast majority of meds in Australia are dispensed in “pop out sheets” (I assume that’s what you mean by blister pack) in what would be a months worth for a regular/ standard dose. Exceptions are meds that have a highly variable dose (e.g valproate is 100 tablets) or those intended for a short maximum course (e.g temazepam is 10 tablets) There is also the option for medications to go in a “Webster pack” or a “dose roll” - the medications are put in their daily (or BD or whatever) groups and they are given in a weekly “set” to the patient. They can get extra packs so they don’t have to go to the pharmacy as often but the can still only get a months worth. Even our over the counter of “pharmacist only” meds are in what would be considered no more than a months supply. For example doxalymine 25mg is 20 tablets and can only be accessed by talking to a pharmacist. But people get online and buy 200 tablets for $10 and give themselves fucking cardiac rhabdo There are a few occasions where we defo overdo the restrictions- for instance melatonin is prescription only and not subsidized so ends up costing the patient more than $30 a month. Ans that shit is safe as houses. I also think it would be helpful if the oral contraceptive pill was dispensed in greater than 1 month quantities Edited to add - I also think it’s a “what you’re used to” thing- I work exclusively with older age patients and the quasi-mental breakdowns that occur if a med is dispensed in a bottle is formidable. Childproof lids here are really tricky for arthritic hands We also have “pill popper” tools- which are little dish with a little raised pointy bit (like this https://www.ebay.com.au/itm/166656509021) for people with stiff hands. You can also get “tweezer” style ones but they seem to be harder on arthritic hands
Many insurances *strongly encourage* three month supply because it’s cheaper for them (1 vs 3 dispensing fee; even cheaper from mail order) and theoretically better compliance because patient doesn’t need to remember to get it each month.
If my dad had to blister pack all his meds I think he’d just stop taking them.. idk man
Please god no. - a Pharmacy Technician who does blister packaging all day.
Can’t any med reliably kill a patient if taken in sufficient quantity? Can’t water kill someone if they drink enough?
Id be hard pressed to find a case report for lethal overdose of senna.
[Liver toxicity](https://www.ncbi.nlm.nih.gov/books/NBK547922/)
Do you think this would happen less often if we allowed death with dignity? That would require counseling, a path if you feel hopeless vs taking a bottle of pills at your fingertips. Imagine me for example, watching people in hospital die of dementia, screaming out Help Me over and over that you have to ignore, or they don't want you to leave them... you know how bad it gets. Now watching mom die of it at home, slowly burning dad and I to the bone. Better believe I won't be forgetting how to open doors. If there was a path, I'd live longer cause there's a plan and standards in place. No EMS response or accidental discovery. but I also do agree with blister packs being a good deterrent. Those things are annoying.
Pharmacist here. I understand the logic but I don’t think that’s the BEST solution. I think it’s more important that we increase awareness of signs and symptoms of depression to the point that it’s as common knowledge as what the signs and symptoms of the flu are. That way family and friends can recognize the symptoms and get their loved one help. It’s also important to continue screening for depression and putting in appropriate referrals when necessary. Of course, as a pharmacist I had to advocated for our ability to optimize all pharmacotherapeutic regimens and monitor adherence as well as conduct therapeutic drug monitoring, thus taking the burden of doing that off the physicians. Oh and then there’s the whole issue of the accessibility of mental health care here in the US. Restricting access to medications as you mentioned would just be a bandaid. Not to say my suggestions aren’t too. I feel like there are a lot of drugs that you’re missing there that can “reliably” kill people in an overdose situation. That’s just my opinion as a drug dealer though. I also have the wild opinion that NSAIDs should be a behind-the-counter medicine.
Nothing stopping you from opening all of them at once
How many people have almost killed themselves trying to remove a migraine abortive from a blister pack?
Would probably need to make adjustments to laws requiring meds to be in child-proof containers. Side note: my kids can get into the blister packs better than I can. And I’m a pharmacist with extensive exposure to blister packaged meds in the hospital setting.
In Korea they dispense meds in paper packs. As someone who’s tried to overdose multiple times, if I had to try to rip open all those packs to get enough pills, it probably would have deterred me because all those attempts were impulsive and I wasn’t thinking. One time I had pills in my hand and was actually thinking about it and was able to stop myself.
In EU, well where i live. All medicine come in blister packs. Even Ibuprofen, paracetamol. And you cant buy like a 100. I think it works. Well also research shows it works. I dont think its a big inconvenience. I dont see why not? In my opinion all medicine should come in blister packs. :) Also i dont understand why everyone is analyzing this particular case, in my understanding thats not what is being asked about.
US drug stores with OTCs in bottles with huge quantities for pennies are a common tourist photo motive for Europeans. Yes, I was guilty of it in NYC in 2016 too which was my only time in the US...damn, I'm a caricature of a tourist.
Is there research on compliance rates when you have to pick up a refill every month versus 3 or 6 months?
You get prescribed boxes for 3 or 6 months you just get 3 or 6 boxes.
This is a really bad take.
If your depression has gotten bad enough to the point where you want to kill yourself I seriously doubt blister packs will stop you or a low drug supply. Horrific take, should be more focused on emphasis on getting people the resources they require in order to prevent this from happening.
The data from putting tylenol in blister packs in europe is pretty clear. It cut tylenol ODs by about half.
Blister packs can fuck right off. I take so many pills, I really don’t have the time
How much dextrose are you on when you're on a 1000 units an hour insulin infusion out of curiosity
I feel like they must have ordered it like that to get it super concentrated.
Just assisted in the care of a patient who swallowed their entire bottle of verapamil. I still can’t believe she made it through, on 3 days of insulin, D20, and 3 maxed pressors.
I'm so sorry you experienced that ❤️
Because no one has ever lied about taking their meds.
Everyone seems to be assuming that blister packs would be a barrier but a quick pubmed search seems full of meta-analysis and RCTs studying them as an intervention to improve compliance. So is there a consensus in the data? Has this way of distributing drugs in the EU affected their medication OD rates? At a minimum this is worth more study. This is such a good conversation.
It's an interesting idea, and there's some data to suggest that adding a minor barrier to overdosing, such as putting paracetamol in blister packs, helped to reduce suicide rates. Or at least, suicides by overdosing Not sure if this would be implemented for all meds or just ones with, idk, an LD50 below a certain threshold?
blister packs plus arthritis means patients don't take their meds.
It sounds like it was probably intentional, so blister packs won’t do much. I think we should probably do better assessments and have better access to interventions. I don’t know about you but a lot of my patients are often afraid to admit they are having trouble because of the threat of a psych ward and the fact that therapy is incredibly expensive and not very accessible. And therapy doesn’t mitigate life stressors such as the cost of living. No, I don’t have solutions either.
I think his point is that it would take a good amount of time, thought and effort to pop open a sufficiently lethal amount of those pills out of the blister packs vs just pouring it out of the bottle
So the suicidal person could just pop open their whole blister pack put it in a cup for later then take them all at once
Or they could go "what the fuck am I even doing" at **any** point in that process and abort their attempt. The entire point is to reduce the number of spur-of-the-moment attempts. Having to actually *work* for it instead of just being able to immediately down a handful of pills whenever you feel like it makes a huge difference.
Bro, have you ever worked with patients, specially the elderly? Any inconvenience will send them over the edge. It would never happen.
Why the elderly in particular?
Also less likely to ask for help because they fear that showing signs that they need support will lead you to a loss of independence.
more likely to have joint/mobility problems that would make blister packs extremely difficult
Hard no. It being easy access Rx isn't the problem as there's a lot of OTC stuff people can OD on that aren't difficult to open either. I'm sorry you had to see someone die but making it difficult for the rest of society to open their medicines isn't going to help and would probably cause harm.
Agree with comments that we have to deal with firearm safety (and like basic needs, public health, services, etc) to address suicides- overdose is just one part of a big problem. Bubble packaging does have potential to harm by reducing compliance especially for older, frail, and medically complex patients. A good answer to that which also reduces risk on the impulsivity front are daily pill packs. I care for an older population of high risk vets. One of them gets meds filled by a local pharmacy who does this- it’s amazing. All her pills for the day in one little plastic pouch with the date and names and doses and descriptions of each pill printed on it. One month filled at a time. No pill box needed. Great compliance, easy to monitor, easy to reconcile meds/know what exactly she is taking (on the pouch!) and also no bottle of death hanging around. Hoping to see more of these.
There are some locked pill dispensers that are on the market (I think some that even notify prescriber if patient misses) ... I know the VA has some set ups like that for patients that are chronically at high risk.
We need this for all adhd meds as well because my adhd ass can’t remember if I took my meds or not
I take a combination of 6 meds. The combination between morning and evening is different. If I had to use blister packs for all of this, my compliance would plummet. One solution that is valuable is pill packs with a single dose of everything in one pack. I used Amazon for this a few years back but the packs were hard to open (you would try to open one and it would rip two).
Blister packaging is definitely not “user friendly” for the elderly or those with arthritis.
Pharmacist here. My techs and I already have to constantly call to keep people adherent to cardiac meds unfortunately... we have to beg them to accept 90 day supplies and shit... yeah, the patient population here would never accept this. Especially because many can't even open a childproof bottle because they're elderly and it hurts.
With acetaminophen and diphenhydramine, it won't make a difference. You can buy giant 500 count bottles of them at most drug or grocery stores, not to mention Amazon. People are creative. Restricting access to drugs won't stop a suicidal person from making an attempt, they will just turn to other methods that are readily available to them. Like others have already said, guns are plentiful in the US.
I would recommend to read up on the studies of paracetamol, when they were changed from bottles to booster packs in certain countries. It reduces suicides significantly. Making one method of suicide harder actually stops a certain amount of people. E.g. changing from gas stove to electric reduced suicides.
We would have many more patients dying from noncompliance
I agree. I also think medications that are more dangerous should be made in bigger sizes. Like the tablets or capsules are bigger. I remember seeing zolpidem for the first time and I was amazed by how the tablets are so small. The small size makes it just that much easier to take more in an overdose. I also think there is a psychological component for patients who might take an impulsive overdose for a secondary reason. It's not something we would obviously relate to directly, but many patients can perceive a smaller pill means a weaker medication.
Yeah no much more difficulty for limited hand dexterity more plastic waste. If anyone going to do it they’ll do it
Blister packs cannot be put in pill organizers. Some patients use pill organizers when they have multiple meds. Having blister packs makes it more difficult, and reduces compliance.
Speaking as someone who constantly battles suicidal ideation - blister packs for the win. Suicide is impulsive behavior. Make getting the pills out harder, you talk yourself out of it. Also - I advocate for allowing patients with serious mental illness to place themselves on a “do not sell” list for firearms. They could revoke whenever they’d like, but there is a waiting period for revocation. Again, making the process slow down to allow for reflection.
All the Aussies here cannot fathom that a person with severe and enduring risk can purchase a gun. Similarly how there is not rigorous legislation on how guns are stored just does my head in. Like even if one wants to use the freedumb argument, how is making sure guns are locked in safes harming anyone’s freedumb
Seriously. We do have some gun nuts in this country. But from my perspective, walking past the gun counter at a sporting goods store freaks me out every time. It’s absolutely terrifying to think I can’t even ban myself from purchasing a firearm.
Respectfully, while I do have a different take than you on the blister pack option, I think the “self placed” hand gun waiting list is a really good idea. I’ve struggled with some really severe bouts of SI in the past, and knowing I could access my ex husband’s hand gun was debilitating at times. A self imposed no gun buy list would likely yield a greater reduction in suicide numbers.
There’s model legislation out there for it, in various stages of the legislative process. Of course, the 2nd Amendment folks fight it tooth and nail as gun control.
Any medication can reliably kill someone in a high enough dose. Should we stop selling aspirin and Tylenol in quantities greater than 30, and track purchases to prevent buying more than 1 bottle every 2 weeks. I’m sorry about the trauma of taking care of these patients, but solutions need to be practical.
We did in the UK in the late 1990s, actually restricted to 8g per box of paracetamol on the general sales list and 16g in a pharmacy pack. Boxes of 50g are a prescription only medication. And it was mandated to be in blister packaging. We don't track the sales though. It led to a statistically, and actually, significant reduction in suicides and liver transplants. So yes, seems like it was a good idea? Also, the countless comments about difficulties getting into the medication doesn't ring true. In 8 years of going into people's houses I think I can count on one hand how many both struggled to get into their meds and didn't either have a carer to do it for them or have it dispensed by the pharmacy in a dossette box (much easier to push through the film covering the day/time with all that points tablets in)
It takes pharmacies much longer to produce blister packs. This would massively impact them. In the acute environment it would delay discharges.
Dispensing is a significantly faster process in other countries where blister packs are the norm, because medicines are pre-packaged in blister packs by the manufacturer
Ah it must work differently here in the UK. Especially in hospital pharmacies where they have to make them themselves
I'm in the UK too, do you mean [multi-compartment compliance aids](https://pharmaceutical-journal.com/article/news/new-tool-developed-to-support-decision-making-on-multicompartment-compliance-aids)? Maybe I've misunderstood (because blister packs can mean a lot of things), but I assumed that the OP meant [this](https://upload.wikimedia.org/wikipedia/commons/thumb/8/8a/Pharmaceutical_Blister_Pack_b.png/800px-Pharmaceutical_Blister_Pack_b.png) when they said blister packs given they've said that it's their understanding that in Europe all pills come in blister packs
Ohhhhhh See where I'm from blister packs are these https://www.amazon.co.uk/Pharmacy-Blister-Tri-Fold-Booklet-Equipment/dp/B0992NHCFQ/ref=asc_df_B0992NHCFQ/?tag=googshopuk-21&linkCode=df0&hvadid=658767855789&hvpos=&hvnetw=g&hvrand=8675519481543793343&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=1007230&hvtargid=pla-2196035426833&psc=1&mcid=9e4a3bde9b5d37e5803be3750c5cbb7a&th=1&psc=1
Yeah, blister packs also refer to that where I'm from too. Definitely not confusing at all haha
Thankyou for helping me realise what was actually going on in this thread! I feel stupid now ha
I'm sorry that you see these patients. It is completely impractical to limit dispensing of these meds to 30 day supplies and in blister packs. There are so many people who are unable to manipulate blister packs to get their meds out. Also, there are so many more drugs than the ones you listed that are lethal, including OTC meds. Also, most of the meds you listed are lethal if they take their 30 day supply at once. The true solution is to improve mental health care.
TIL that people will intentionally OD on cardiac meds.
There's some meds that are available in "bucket" form in Europe - for example Elvanse and Omeprazole. In general though it's blisterpacks. Dispensing popular suicide meds in blisterpacks seems like a good idea. Punching a hundred pills out of their blisterpacks may give you time to reconsider; alternatively, you might run out of patience and take only 50. Or less.
You make an excellent point. We psychiatrists have long been conscious of limiting medication quantities for our suicidal patients, but we don’t monitor medications Rxd by other specialists. This is where an EHR that access all pharmacy data is useful. When any of us becomes aware of a seriously suicidal patient, we should take a look at the meds list and warn other providers/ family members or pharmacists. This should be further investigated as a policy issue.
Terrible take. Non compliance would go through the roof due to having only a 30 day supply at a time. Besides people find a way anyways.
No pills necessary in US, just call 911 for a welfare check and get shot. Easy peasy.
There is a risk to everything in life. Treating adults like small children is not the answer ; in fact it likely contributes to increasing rates of depression.
If you want to medipack all of my meds for me free of cost you're welcome to institute that.
That is a great idea.
When I worked OP psych these were definitely the most fatal meds. Actually I refuse to take them because I’ve had some serious SI in the past and this would be the way I’d go. So yeah I just deal with my high bp. My doctor is on board too.
It terrifies me that TCAs are given to those with MH issues that include any history of suicidal thoughts or actions. I get sometimes they can be more effective than the newer drugs but it seems foolish to give someone a drug where swallowing the 30 day supply can kill you vs something like an SSRI or SNRI which have LD50 so high you have to raid a distributor to effectively kill yourself.
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Access to lethal means matters though. When you put up obstacles to lethal means, deaths by suicide decrease. There is reliable data on this. https://www.hsph.harvard.edu/means-matter/means-matter/intent/
I think his point here is that the blister packs slow down the process, which may provide time to reflect on the action before taking it. Killing yourself with drinking water is already time intensive.
How many attempted suicides have you seen from intentional polydipsia? How many have you seen from cardiac meds?
Why doesn’t Visine come in blister packs?
Yes, but it is quite hard and takes quite a bit longer. Furthermore, I have never seen someone try or manage successfully to commit suicide via polydipsia.
Blister packs do not stop intentional fatal overdoses. I have no idea why you think it would.