How the "Opioid Epidemic" Has Exposed the Hidden Dangers of Acetaminophen
By Don Drake, Connelly Law Offices, Ltd.
"The number of seniors struggling with substance use disorders has almost doubled since 2006, affecting almost six million older adults," stated Attorney RJ Connelly III, a professional fiduciary and certified elder law attorney. "Seniors with substance use problems face more risks than younger people due to several factors such as cognitive impairments, medication interactions, nutritional concerns, poor social supports, and the risk of falls. Misusing or abusing substances and medications is also linked to higher mortality rates and increased healthcare costs."
The National Institute on Drug Abuse (NIDA) reports that between 4 and 9 percent of older adults aged sixty-five and above use prescription opioids to manage their pain. Moreover, NIDA reveals that opioid prescriptions for older adults increased by a factor of nine. Opioids are classified as Schedule II drugs due to their highly addictive qualities and potential for dependence.
"The 'opioid epidemic' has forced many providers to reduce these prescriptions and rely on over-the-counter pain reducers for their patients," said Attorney Connelly. "Obviously, over-the-counter pain relievers such as acetaminophen (Tylenol) do not have the same potency as opioids. Therefore, many older adults are taking more acetaminophen than recommended to control their pain. This puts them at risk of accidental overdose, liver damage, and other serious health problems. We are going to discuss some of these hidden dangers of acetaminophen in today's blog."
The Concerns with Acetaminophen (Tylenol)
Acetaminophen, commonly known as Tylenol, is a widely used over-the-counter pain medication that is considered safe when taken as directed. However, there are growing concerns among geriatricians regarding its misuse and overuse, which can cause significant damage, particularly in seniors.
As Attorney Connelly points out, the opioid epidemic has partly contributed to this situation, with the medical community becoming more reluctant to prescribe stronger pain medications for appropriate pain control. As a result, seniors are now more likely to turn to over-the-counter medications such as acetaminophen and ibuprofen to manage their pain.
Pain is a common condition among seniors and is more prevalent than diabetes, heart disease, and cancer combined. However, due to the medical profession's reluctance to prescribe stronger pain medications, seniors are now taking these over-the-counter drugs more frequently, which can lead to complications.
The problem is that seniors tend to have a slower metabolism, which means their bodies cannot clear medication as quickly as younger people's bodies. This can lead to toxicity and even overdose, especially with certain medications. Aging brings physical changes to the body as well, including a reduction in muscle mass, an increase in fat tissue, changes in body composition, and less fluid in the body systems. As a result, senior bodies react differently to medications than when they were younger. Acetaminophen is one such medication that can cause life-threatening complications in some cases. It is, therefore, crucial that seniors take acetaminophen as directed and only when necessary to avoid the risk of adverse effects.
Manny lived alone in the Hyde Park neighborhood of Boston. At the age of sixty-three, he was forced to retire early from his construction job due to severe arthritis, which had robbed him of using his hands and shoulders to earn a living as a construction worker. "I started with arthritis early on, by my mid-forties, it had gotten really bad," Manny said. "All the years of working in the damp and cold just took its toll on me. I tried to get disability but by the time my case would work itself through the system, I would reach retirement age, so I just took early retirement."
For years, Manny was taking Vicodin (acetaminophen/hydrocodone) for the pain, which he said seemed to work when necessary. "I didn't use them all the time, only when I needed them, and I needed them most in the fall and winter months. I never had a problem with abusing them," he said. But on one doctor's visit, things changed drastically for him.
"I had this doctor for years; he knew me, but he said that using opioids was not a good idea, and he just stopped prescribing them for me even though he knew how much pain I was in. He suggested I use extra-strength Tylenol or some other acetaminophen over-the-counter product. He gave me some story about the epidemic of opiates and the dangers of addictions. He made me feel like a drug addict," Manny explained. "Rather than argue and make myself look like an addict, I followed his advice and started taking [acetaminophen]."
Manny began using extra-strength [acetaminophen], 500mg tablets, taking eight a day, which is at the limit of the safe recommended dosage. "They did nothing to help my pain, especially in the wintertime. I started taking more, ten to twelve pills a day on average, sometimes more," he stated. "That didn't help either. But what did help is when I used rum and [acetaminophen]. It became a great pain reliever for me and also helped me sleep."
Although his doctor had discussed the opioid epidemic with him and the dangers of addiction, what he did not discuss was the dangers of using too much acetaminophen or mixing it with alcohol.
"The winter of a couple of years ago was really rough, so I would drink a little rum in the morning to help the [acetaminophen] kick in. But I needed more to get the same effects," Manny said. "Then, I started getting an upset stomach and threw up anything I would eat. What the hell was I supposed to do? I needed something to stop the pain in my body, but when I used [acetaminophen] and rum, I got so sick I couldn't function. I was a mess."
One Sunday morning, he woke up and noticed that his eyes were turning yellow, and his urine was a deep brown color. "When I got up that morning, I had back pain, and when I went to the bathroom, it actually looked just like the rum I was drinking. I knew I was in trouble," Manny stated. He went to the emergency room at Mass General Hospital and was admitted after being diagnosed with acetaminophen hepatotoxicity.
"They gave me a bunch of medicine through IV and said my liver was damaged, but it would heal itself, as long as I stopped drinking and using [acetaminophen]. My question to my doctor was why he didn't warn me about these dangers. Yeah, I shouldn't have drank while taking these, but what was I to do for the pain? He was so worried about addiction, but I almost killed myself with over-the-counter medicine to stop the pain. I need to work for a living. Where's the common sense here?"
The Liver and Acetaminophen
When this medication is taken in the recommended dose, it is initially broken down in the gastrointestinal tract and then absorbed by the bloodstream. This process usually takes around 45 minutes orally but can take up to two hours for older adults who may be taking suppositories. Once absorbed, acetaminophen is metabolized by the liver and excreted in the urine.
Taking too much acetaminophen can have serious consequences. When a high amount of acetaminophen is consumed, it can cause an increase in a toxic by-product known as N-acetyl-p-benzoquinone imine (NAPQI). Normally, the liver can effectively clear small amounts of NAPQI, but in larger amounts, it can kill cells and cause irreversible tissue damage. In severe cases, acetaminophen overdose can even lead to liver failure and death.
According to a 2016 literature review, liver failure caused by acetaminophen overdose resulted in death in approximately 28 percent of cases, and among those who survived, 29 percent required a liver transplant. Even those who survived an acetaminophen overdose without needing a liver transplant experienced long-term liver damage.
It's important to note that even taking acetaminophen at just 25 percent above the recommended dosage for several days can cause liver damage. The recommended dose is not to exceed 4000 milligrams (mg) daily, with 3000 mg being the recommended dose. A report in the American Journal of the American Medical Association states that even this dosage over 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 damaging effects continue for several more days.
Moreover, for those who may be prescribed a narcotic like hydrocodone or codeine, using acetaminophen to address breakthrough 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.
Recent studies show that acetaminophen overdose causes over 100,000 people to visit hospitals annually, with several hundred dying of liver failure. Over half of acute liver failure cases in the United States are the result of acetaminophen overdose. It is therefore important to always follow the recommended dosage and to seek medical help immediately if you suspect an acetaminophen overdose.
Alcohol Use and Acetaminophen
Most of us know that chronic alcohol consumption can have detrimental effects on the liver. However, when combined with acetaminophen, the risk of liver damage and stomach bleeding increases significantly. Even though either of these substances can cause liver damage on their own, the consequences of their combined use can range from minor to extremely critical. Individuals diagnosed with alcohol use disorder (AOD), previously recognized as alcoholism, should avoid using acetaminophen altogether because any consumption could be hazardous.
Acetaminophen manufacturers recommend that people who consume three or more drinks per day should discuss their alcohol use with their healthcare providers. It is vital to understand that there is no safe amount of acetaminophen dosing when using alcohol regularly, as the risk of liver damage and stomach bleeding is always present.
The Stomach and Acetaminophen
Regular use of acetaminophen in doses exceeding 2000 mg increases the risk of upper gastrointestinal tract bleeding by four times compared to those who do not take it regularly. As per a blog post published on the Kressler Institute website, high doses of acetaminophen can cause damage to the liver, leading to the release of a protein that causes intestinal permeability. Consequently, bacteria can leak from the gut directly into the bloodstream, leading to a potential blood infection. In certain cases, these bacteria may even show resistance to antibiotics, making the situation even more concerning. It is, therefore, crucial to use acetaminophen responsibly and only as directed by a medical professional.
The Heart, Kidneys, and Blood
When taken as directed and without the use of alcohol, acetaminophen is generally considered to be a safer option for your heart than ibuprofen products. However, it is important to note that each individual's medical needs and history may differ, and it is always recommended to consult with a medical provider before taking any medication.
While acetaminophen may be considered safer for the heart, it has been associated with potential risks to the kidneys. Heavy use of acetaminophen, particularly when combined with alcohol use, has been linked to an increased risk for kidney disease. Various studies have also identified a potential correlation between acetaminophen and kidney cancer.
In addition to kidney risks, acetaminophen has been associated with several blood cancers, including myeloid neoplasms, non-Hodgkin lymphomas, and plasma cell disorders like multiple myeloma. These findings were revealed in a 2011 study of over 64,000 men and women, indicating the need for caution when using acetaminophen for prolonged periods. It is advisable to discuss any concerns or questions about medication risks with a healthcare professional.
Other Effects of Acetaminophen
Acetaminophen has been linked to rare but potentially serious skin conditions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Stevens-Johnson syndrome is a rare but severe allergic reaction to certain medications that often starts with flu-like symptoms and is followed by a painful rash that spreads and blisters. The affected skin's top layer then dies, sheds, and gradually heals over several days.
Toxic epidermal necrolysis is another life-threatening skin condition characterized by a blistering and peeling of the skin, which can be caused by a reaction to other drugs present, often antibiotics or anticonvulsants. Although the exact mechanism by which acetaminophen triggers these reactions is not yet fully understood, it is crucial to be aware of these potential side effects.
In addition, a recent study has found that regular use of acetaminophen may slightly increase the risk of stroke in people with diabetes. Hence, it is imperative to consult a healthcare professional before taking this medication, especially if you have a pre-existing medical condition.
A study conducted by Ohio State University explored the potential impact of acetaminophen on emotional processing. The findings of the study revealed that individuals who regularly consumed acetaminophen tended to evaluate unpleasant stimuli less negatively and pleasant stimuli less positively as compared to those who took a placebo. This implies that both negative and positive events were less emotionally stimulating to those who consumed acetaminophen, thereby blunting their reaction towards such events.
Furthermore, another double-blind study conducted by a different research group at Ohio State University found that individuals who consumed acetaminophen displayed less empathy toward others' pain after taking the medication. These results raised concerns about the social implications of acetaminophen use and the possible impact it may have on an individual's ability to relate to others.
Acetaminophen in Disguise
It is worth noting that Acetaminophen can be present in several OTC and prescription medications without the user's knowledge. Some common cold medications like Theraflu and Sudafed, as well as several allergy medications, contain Acetaminophen as an ingredient. This can lead to unintentional overdosing, especially in older individuals who may be taking Tylenol for arthritis and Nyquil for a cold without realizing that the cold medication also contains Acetaminophen.
It is essential to read the label of any OTC medication one takes and pay attention to the ingredients. Even if one reads the ingredients, Acetaminophen may not always be spelled out; instead, abbreviations such as APAP, Acetaminoph, Acetaminop, Acetamin, or Acetam may be used. Therefore, if you have any questions about what is contained in any medication, it is advisable to ask your pharmacist or health provider.
"As mentioned earlier, medical professionals emphasize that acetaminophen products are considered safe when taken within the recommended dosage and without consuming alcohol," said Attorney Connelly. "According to providers, the recommended dosage for adults is typically between 650 mg and 1,000 mg of acetaminophen every 4 to 6 hours. The FDA recommends that an adult should not exceed 3,000 mg of acetaminophen per day unless guided otherwise by their healthcare professional. It's essential to adhere to the recommended dosage to avoid any potential health risks."
Here are some points to remember when taking acetaminophen products:
Limit the use of Tylenol or acetaminophen products to no more than ten consecutive days, although some healthcare professionals recommend using them for as little as five days unless instructed otherwise by a doctor. This information is important for maintaining your health and avoiding potential side effects from prolonged usage.
When alcohol is mixed with Tylenol/acetaminophen products, it can cause damage to the liver, which may result in liver failure or other serious health issues. The combination of alcohol and acetaminophen can also increase the risk of gastrointestinal bleeding and stomach ulcers. Therefore, it is highly recommended to avoid consuming alcohol while taking Tylenol/acetaminophen products. If you are unsure about the safety of combining these substances, please consult with your healthcare provider.
It is also important to note that the combination of acetaminophen with certain other drugs or alcohol consumption can increase the risk of kidney disease. This is because the kidneys are responsible for filtering out the acetaminophen and its byproducts, and excessive use of this medication can overload the kidneys, leading to kidney damage. Use acetaminophen as directed and avoid combining it with other substances unless specifically advised by a healthcare provider.
To ensure your safety, it's recommended that you do not take more than 3,000 mg of acetaminophen within a 24-hour period. If you are taking it on a regular basis, seek medical advice to determine the appropriate dosage for your individual needs.
"As we grow older, it becomes imperative to prioritize the safety of all medications, including Over-The-Counter (OTC) drugs that are commonly used by the elderly but viewed as not being as dangerous as prescribed medication," stated Attorney Connelly. "With the ongoing opioid epidemic, healthcare professionals are now more cautious about prescribing stronger narcotic pain relievers. Consequently, individuals with chronic pain issues, particularly older adults, are resorting to OTC NSAIDs and acetaminophen for relief. Remember, just because a medication can be purchased over the counter does not mean it is entirely safe. Always consult with your healthcare provider before consuming any medication."