Last month was National Recovery Month, a national observance held every September by the Substance Abuse and Mental Health Services Administration (SAMHSA) to promote and support new evidence-based treatment and recovery practices, the emergence of a strong and proud recovery community, and the dedication of service providers and community members across the nation who make recovery in all its forms possible. Recovery month is in its 32nd year and celebrates the gains made by those in recovery from addictions. And to observe this month, our blogs will feature information on substances of abuse that affect our seniors whether it be a substance use disorder, dangers of mixing medications, or those contributing to cognitive issues or falls.
"Substance use disorders among our seniors have nearly doubled since 2006, affecting almost 6 million older adults," said Attorney RJ Connelly III. "The reality is that seniors with a substance use problem face many more risks than younger people due to cognitive impairments, medication interactions, nutritional concerns, poor social supports, and the risk of falls. Misusing or abusing substances and medications is also linked to increased mortality rates and higher costs of healthcare."
Americans continue to have a stereotypical view of substance abuse and addiction. It happens to the “other family” -- not ours. Many believe it is a problem of the “lower class”, those lacking education, the young, the homeless, and even minorities. These are stereotypes and stereotypes die hard because, in most cases, they are the refuge of those who are neck-deep in denial. In truth, addiction and abuse can be found in every family, every culture, every economic class, and, as we discussed in our September blogs, at any age.
In this week's blog, our final one in honor of National Recovery Month, we will look at the dangers of acetaminophen products, better known as Tylenol, among users, especially seniors. These dangers are becoming more apparent as individuals seek other forms of pain relief because the opioid epidemic has caused prescribers to cut back on the number of prescriptions written for stronger pain control medications.
Is Tylenol (Acetaminophen) Dangerous?
So let's begin this blog by stating that taken as directed, acetaminophen (Tylenol) is a relatively safe over-the-counter medication. But, there are increasing concerns among many geriatricians about the damage that is caused by the misuse and overuse of acetaminophen to address pain. As we stated earlier, some of this is the result of the opioid epidemic and the medical profession's reluctance to now prescribe these medications for pain control.
When it comes to seniors, pain is a more common condition and complaint than diabetes, heart disease, and cancer combined. With the medical profession's cut back in prescribing stronger pain control medications, seniors are taken more over-the-counter medications like acetaminophen and ibuprofen.
As pointed out in previous blogs, a senior's inability to clear medications as quickly as a younger person's system can lead to toxicity and even overdoses with certain medications. And, because older adults experience physical changes as they age including reduced muscle mass, more fat tissue, changes in body composition, and less fluid in the body systems, the way their body reacts to medications that they could previously use without negative reactions may change. Acetaminophen is one of these medications.
The Liver and Acetaminophen
When taking a normal dose of this medication, it is initially broken down in the gastrointestinal tract and then absorbed by the bloodstream. Normally, this takes about 45 minutes and for older adults taking suppositories, up to two hours. Then, it is metabolized by the liver to be excreted in the urine. But taking too much acetaminophen can change the way the liver does its job. A high amount of this medication causes an increase in a metabolite (the by-product of metabolism) called N-acetyl-p-benzoquinone imine (NAPQI), a toxic by-product.
Normally, the liver can effectively clear small amounts of NAPQI, but in larger amounts, it kills cells and causes irreversible tissue damage. In severe cases, it can cause liver failure leading to chain reactions that can lead to death.
In a 2016 literature review by Trusted Source, liver failure caused by acetaminophen overdose caused death in approximately 28 percent of cases and among those who survived, 29 percent required a liver transplant. Those who survived an acetaminophen overdose without needing a liver transplant experienced long-term liver damage.
Here is another shocking statistic, those who take acetaminophen over a period of several days at just 25 percent above the recommended dosage, have been shown to experience some liver damage. The guidance on acetaminophen use states that individuals should not take more than 4000 milligrams (mg) daily (with 3000 mg being the dose recommended). But according to a report in the American Journal of the American Medical Association, even this dosage over a period of four days or more can cause an elevation in ALT (serum alanine aminotransferase) levels, which is a sign of liver damage. The report also states that even when acetaminophen is discontinued, the damage continues for several more days.
For those who may be prescribed a narcotic like hydrocodone or codeine, using acetaminophen to address break-through pain increases the chances that a toxic reaction could occur. This is because acetaminophen depletes levels of the body's master antioxidant glutathione, which protects cells from damage caused by free radicals.
In fact, recent studies show that acetaminophen overdose causes over 100,000 people to visit hospitals annually with several hundred dying of liver failure. Further, over half of acute liver failure cases in the United States are the result of acetaminophen overdose.
Chronic alcohol use combined with acetaminophen can increase the dangers of liver damage and stomach bleeding. As we stated earlier, either one of these substances can cause liver damage by itself but combined, the damage ranges from minor to extremely critical. For those diagnosed with alcohol use disorder (AOD), known in the past as alcoholism, any use of acetaminophen could be dangerous. Those who manufacture acetaminophen recommend that anyone who consumes three or more drinks daily discuss alcohol use with their providers. "There is a bottom line here," said Attorney Connelly. "There is no safe amount of acetaminophen use when using alcohol."
A Healthy Stomach
A person who uses acetaminophen on a regular basis at doses greater than 2000 mg. faces nearly a four times greater chance of stomach bleeding in the upper gastrointestinal tract. According to a blog on the Kressler Institute site, high levels of acetaminophen that causes damage to the liver releases a protein that causes intestinal permeability resulting in bacteria leaking from the gut directly into the bloodstream. The result could be a full-blown blood infection and in some cases, these bacteria could be resistant to antibiotics.
Your Heart, Kidneys, and Other Diseases
Taken as directed and without the use of alcohol, acetaminophen is healthier for your heart than ibuprofen products, again, this is a general statement and each person should check with their medical provider. The kidneys, however, are another story.
Heavy use of acetaminophen has been associated with risk for kidney disease especially when combined with alcohol use. At least one study found an elevated risk of kidney dysfunction when using alcohol and acetaminophen together and in a 2013 study, acetaminophen has also been found to have some correlations with kidney cancer. Finally, in a 2011 study of more than 64,000 men and women, acetaminophen was associated with several different types of blood cancers including myeloid neoplasms, non-Hodgkin lymphomas, and plasma cell disorders like multiple myeloma.
Acetaminophen use has also been linked to rare but serious skin conditions such as Stevens-Johnson syndrome (a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters. Then the top layer of affected skin dies, sheds, and begins to heal after several days) and toxic epidermal necrolysis (a life-threatening skin disorder characterized by a blistering and peeling of the skin. This disorder can be caused by a drug reaction - often antibiotics or anticonvulsives). Exactly how acetaminophen causes these reactions are still in question but it's important to keep in mind.
Finally, in another study, researchers found a slightly elevated stroke risk in those with diabetes who used acetaminophen on a regular basis.
In an Ohio State University study, it appeared that acetaminophen affected emotional processing. According to researchers, those using acetaminophen on a regular basis
“evaluated unpleasant stimuli less negatively and pleasant stimuli less positively, compared with participants who took a placebo.” Plainly speaking, both negative and positive events were less emotionally stimulating to those taking acetaminophen, in essence blunting reaction to such events. In another double-blind study by another research group at Ohio State, they found acetaminophen users exhibited less empathy towards others' pain after taking the medication. The results of this study raised questions about the social implications of acetaminophen use.
Acetaminophen in Disguise
Acetaminophen may also be contained in other OTC and prescription medications without the user having knowledge of this. Cold medications such as Theraflu and Sudafed and several allergy medications have acetaminophen as an ingredient. "Older individuals taking Tylenol for arthritis and Nyquil for a cold without realizing the cold medication also contains acetaminophen may be doubling their dose without even realizing it," said Attorney Connelly. "It's important to read the label in any OTC medication you are taking." He also points out that acetaminophen may not always be spelled out even if you read the ingredients. "Abbreviations such as APAP, Acetaminoph, Acetaminop, Acetamin, or Acetam may be used instead, so any questions about what is contained in any medication need to be asked of the pharmacist or your health provider."
PM Pain Relievers
"Seniors need to take extra precautions when using PM pain relievers," said Attorney Connelly. "Because they often contain diphenhydramine as a sleep aid, they can cause confusion, falls, blurred vision and urinary issues in older adults."
"Medical professionals I speak with say the acetaminophen products are relatively safe when taking the recommended dosage," continued Connelly. Medical providers state that the recommended dosage for adults is between 650 mg and 1,000 mg of acetaminophen every 4 to 6 hours and the FDA recommends that an adult shouldn’t take more than 3,000 mg of acetaminophen per day unless directed otherwise by their healthcare professional.
Here are a few things to remember when taking acetaminophen products:
Don’t take Tylenol or acetaminophen products for more than 10 days in a row (some medical providers recommend as little as five days) unless you’ve been instructed to do so by your doctor.
It can be harmful to mix alcohol and Tylenol/acetaminophen products.
The biggest concern is damage to the liver, but this combination can also increase the risk of kidney disease.
You should never drink more than three alcoholic beverages in a day, and you should always make sure you’re not combining Tylenol with any other medicine that contains acetaminophen. Read the labels!
You should never take more than 3,000 mg of acetaminophen in a day and to be safe, if you are using it on a regular basis, seek medical advice.
"As American ages, we need to focus on the safety of all medications, including OTC medications that our older population uses," said Attorney Connelly. "This is especially true since the opioid epidemic has resulted in health professionals severely cutting back on the prescribing of stronger narcotic pain relievers. This has resulted in those with chronic pain issues, specifically older adults, seeking relief through OTC NSAIDs and acetaminophen. It's always best to check with your health care provider before taking or mixing any new medication to make sure you're taking the dose that's right for you."