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The Potential Dangers of Acetaminophen

The Potential Dangers of Acetaminophen When Misused

by Don Drake, Connelly Law Offices, Ltd. 3.31.24


Medicaid Planning Rhode Island
Attorney RJ Connelly III

"Recently, someone shared a troubling experience involving his mother-in-law and her use of acetaminophen (Tylenol). After being taken off Vicodin, which she had been using for years to manage spinal stenosis pain, she was advised by her doctor to use acetaminophen for relief. Unfortunately, she ended up in the hospital after consuming more than the recommended dosage for several weeks. She stated that the Tylenol was ineffective in managing her pain, which led her to exceed the recommended dosage," said professional fiduciary and certified elder law Attorney RJ Connelly III.


"Opioids, like Vicodin, are classified as Schedule II drugs, emphasizing their highly addictive qualities and potential for dependence," continued Attorney Connelly. "The 'opioid epidemic' has forced many providers to cut back on these prescriptions and are now depending on over-the-counter pain reducers for their patients. The problem is that they do not have the same potency as opioids, and as a result, many, especially seniors, are taking more acetaminophen than indicated to control pain. After hearing the story about the woman who overdosed on this medicine, it's crucial to revisit this topic, as many individuals underestimate the potential dangers associated with over-the-counter medications such as Tylenol. Despite being easily accessible, these medications can pose significant toxicity risks if not used appropriately."


About Acetaminophen

The use of acetaminophen (Tylenol) as directed is generally safe as an over-the-counter medication. However, many geriatricians are increasingly concerned about the potential harm caused by the misuse or overuse of acetaminophen to manage acute and chronic pain. This concern has arisen partly due to the opioid epidemic and the medical profession's current reluctance to prescribe opioids for pain management.


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Doctors are prescribing fewer narcotic pain relievers

When it comes to seniors, pain is a more common condition and complaint than diabetes, heart disease, and cancer combined. As stated earlier, the medical profession is now reluctant to prescribe more potent pain control medications; seniors are increasingly turning to over-the-counter medications such as acetaminophen and ibuprofen. And we need to understand how they work on an older person.


As we age, our bodies undergo physical changes that affect how we metabolize medications. Seniors have a slower metabolism and cannot clear medications as quickly as younger people. This can lead to toxicity and even overdose with certain medicines. The changes in our bodies include a reduction in muscle mass, an increase in fat tissue, changes in body composition, and less fluid in the body systems. Consequently, our bodies react differently to medications they could previously metabolize without adverse reactions.


Manny's Story

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 awful," Manny told us. "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."


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Manny was no longer prescribed Vicodin

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 started using extra-strength acetaminophen, 500mg tablets, at the maximum safe dosage of eight pills a day. However, he found that they provided little relief for his pain, especially during the winter. As a result, he began taking more, averaging ten to twelve pills a day, sometimes even more. Despite this, he still found no relief. Eventually, he discovered that combining rum with acetaminophen provided effective pain relief and helped him sleep.


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"I couldn't take the pain anymore."

Although his doctor had discussed the opioid epidemic with him and the dangers of addiction, what he did not discuss was the dangers of taking too much acetaminophen or mixing it with alcohol.


"The winter of a couple of years ago was 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 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. "When I got up that morning, I had back pain, and when I went to the bathroom, it 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 (acute or chronic liver injury secondary to drugs).


"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. Where's the common sense here?"


The Liver and Acetaminophen

When you take the recommended dose of acetaminophen, it is first broken down in the gastrointestinal tract and then absorbed into the bloodstream, which typically takes about 45 minutes. For older adults using suppositories, this process may take up to two hours. The acetaminophen is then metabolized by the liver and excreted in the urine. However, taking too much acetaminophen can impact the liver's function. An excessive amount of this medication can lead to an increase in a toxic by-product called N-acetyl-p-benzoquinone imine (NAPQI).


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Liver failure can result from acetaminophen misuse

Under normal circumstances, the liver can effectively eliminate tiny amounts of NAPQI. But in larger quantities, it can cause cell damage and irreversible tissue damage. In severe cases, it can even lead to liver failure and potentially be fatal.


In a 2016 literature review by Trusted Source, it was found that liver failure caused by acetaminophen overdose resulted in death in approximately 28 percent of cases. Among those who survived, 29 percent required a liver transplant. Even those who survived without needing a transplant experienced long-term liver damage.


Another concerning statistic is that individuals who take acetaminophen at just 25 percent above the recommended dosage over several days have been shown to experience some liver damage. The recommended guidance for acetaminophen dosing states that individuals should not exceed 4000 milligrams (mg) daily, with 3000 mg being the recommended dose.


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Do not drink alcohol and use acetaminophen

According to a report in the American Journal of the American Medical Association, even taking this dosage of acetaminophen over four days or more can lead to an increase in ALT (serum alanine aminotransferase) levels, indicating potential liver damage. The report also notes that the damaging effects on the liver continue for several days, even after stopping acetaminophen use.


For individuals who are prescribed narcotics such as hydrocodone or codeine, using acetaminophen to manage breakthrough pain raises the risk of a toxic reaction. This is because acetaminophen depletes the body's master antioxidant glutathione, which protects cells from damage caused by free radicals.


Recent studies indicate that acetaminophen overdose leads to over 100,000 hospital visits annually, with several hundred resulting in liver failure and death. Additionally, more than half of acute liver failure cases in the United States are due to acetaminophen overdose.


Acetaminophen and Alcohol Use

Combining chronic alcohol use with acetaminophen can significantly increase the risk of liver damage and stomach bleeding. While both substances can individually cause liver damage, the combination can lead to a wide range of severity, from minor to extremely critical. For individuals diagnosed with alcohol use disorder (formerly known as alcoholism), even lesser amounts of acetaminophen can pose a serious risk.


Manufacturers of acetaminophen advise individuals who consume three or more drinks daily to consult their healthcare providers regarding their alcohol use. Many medical providers emphasize that there is no safe level of acetaminophen use when consuming alcohol regularly.


Acetaminophen and the Stomach

Regularly consuming more than 2000 mg of acetaminophen can significantly elevate the risk of developing stomach bleeding in the upper gastrointestinal tract. Studies have shown that this risk is four times higher than individuals who do not exceed this dosage. The Kressler Institute's blog sheds light on the detrimental effects of high acetaminophen levels on the liver. It is explained that excessive intake can lead to the release of a specific protein that contributes to intestinal permeability. This can result in bacteria leakage from the gut into the bloodstream, potentially causing a severe blood infection. Furthermore, these bacteria may exhibit antibiotic resistance in some instances, posing additional health risks.


Acetaminophen and the Heart, Kidneys, and Blood

When taken as directed and without the use of alcohol, acetaminophen is considered to have fewer adverse effects on the heart compared to ibuprofen products. It's important to note that acetaminophen should be used cautiously, as heavy use, especially when combined with alcohol, has been linked to an increased risk of kidney disease.


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Kidneys can also be damaged

Additionally, research has shown associations between acetaminophen use and kidney cancer, as well as certain types of blood cancers, including myeloid neoplasms, non-Hodgkin lymphomas, and plasma cell disorders like multiple myeloma. However, individuals need to seek personalized medical advice from their healthcare provider before making any decisions about medication use.


Other Effects of Acetaminophen Use

Acetaminophen use has been associated with 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 blistering and peeling of the skin. This disorder can be caused by a reaction to other drugs, often antibiotics or anticonvulsants). The exact way acetaminophen causes these reactions is still uncertain, but it's important to remember. In another study, researchers found a slightly elevated stroke risk in those with diabetes who used acetaminophen regularly.


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Many OTC meds contain acetaminophen

Acetaminophen in Disguise

Acetaminophen is a common ingredient in both over-the-counter (OTC) and prescription medications, and it's imperative to be aware of its presence to avoid unintentional double dosing. For example, popular cold medications such as Theraflu and Sudafed and certain allergy medications contain acetaminophen. Therefore, it's crucial to carefully read the labels of any OTC medications being used and be mindful that acetaminophen may be listed under abbreviations like APAP, Acetaminoph, Acetaminop, Acetamin, or Acetam. Additionally, seeking clarification from a pharmacist or healthcare provider about the contents of a medication is highly recommended to ensure safe usage.


Some Takeaways

"Medical professionals have emphasized that acetaminophen products are relatively safe when taken at the recommended dosage and without using alcohol," stated Attorney Connelly. Healthcare providers recommend that adults take between 650 mg and 1,000 mg of acetaminophen every 4 to 6 hours. Additionally, the FDA advises that adults should not exceed 3,000 mg of acetaminophen per day unless directed otherwise by their healthcare professional.


Remember the following points when taking acetaminophen products:


  1. It is important to avoid taking Tylenol or acetaminophen products for more than ten consecutive days (some medical professionals recommend even fewer days, such as five) unless expressly advised to do so by your doctor.

  2. Combining alcohol and Tylenol/acetaminophen products can have harmful effects on the body. The primary concern is the potential for liver damage, as both alcohol and acetaminophen can be taxing on the liver. This combination can also elevate the risk of kidney disease, making it important to avoid mixing alcohol with products containing acetaminophen.

  3. Please remember that it is recommended not to consume more than three alcoholic beverages a day. It is also important to avoid combining Tylenol with any other medicine containing acetaminophen. Always carefully read and follow the instructions on the labels of any medications you take.

  4. Remember not to take more than 3,000 mg of acetaminophen in a 24-hour period. If you need to use acetaminophen regularly, consult with a healthcare professional to ensure you are using it safely.


A Final Word

"As the American population continues to age, it is crucial to prioritize the safety of all medications, including over-the-counter (OTC) drugs commonly used by older individuals," stated Attorney Connelly. "This is particularly significant in light of the opioid epidemic, which has led healthcare professionals to reduce the prescription of potent narcotic pain relievers significantly. Consequently, individuals dealing with chronic pain, particularly older adults, have turned to OTC nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen for relief. It's important to note that just because a medication is available over the counter does not automatically guarantee its safety. Always consult with your healthcare provider before using any medication."


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Please note that the information provided in this blog is not intended to and should not be construed as legal, financial, or medical advice. The content, materials, and information presented in this blog are solely for general informational purposes and may not be the most up-to-date information available regarding legal, financial, or medical matters. This blog may also contain links to other third-party websites that are included for the convenience of the reader or user. Please note that Connelly Law Offices, Ltd. does not necessarily recommend or endorse the contents of such third-party sites. If you have any particular legal matters, financial concerns, or medical issues, we strongly advise you to consult your attorney, professional fiduciary advisor, or medical provider.


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