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As a unit, the kiloton is most often linked to the explosive yield of nuclear weapons in tons of TNT (trinitrotoluene, an explosive). For drugs, we are more comfortable with milligrams, a unit one million million times smaller. With paracetamol, at a population level, the kiloton unit may be more appropriate: in Europe, paracetamol sales range from under 200 tons in Greece and Portugal to 6300 tons in the UK and 10 000 tons in France.1 On a per capita basis the range is 4–5 tons per million to 30–50 tons per million. These figures relate to the total population exposure, including over-the-counter (OTC) sales, though prescribing of paracetamol is not negligible. In the UK in 2014, 42 million paracetamol-containing medicines were prescribed at a cost of £191 million,2 and 200 million packs sold OTC.3
Paracetamol was discovered in the 1950s,4 and the general view that it is effective and safe has led to such widespread use. Yet there has been considerable uncertainty over how it works. Only recently has it been generally accepted that it inhibits COX-1 and COX-2 isoenzymes, and is …
Correspondence to Dr R Andrew Moore, Pain Research, Nuffield Division of Anaesthetics, University of Oxford, The Churchill, OX3 7LE Oxford, UK; Andrew.moore{at}ndcn.ox.ac.uk