The Unintended Consequences of the Opioid Epidemic - Increased Tylenol Abuse
by Don Drake, Connelly Law Offices, Ltd.
"The 'opioid epidemic' has had some unintended consequences that many could not have predicted," said professional fiduciary and certified elder law Attorney RJ Connelly III. "The addiction to opioids has forced many providers to cut back on prescribing these pain relievers, even to those who truly need them, forcing individuals, especially older adults, with serious ailments such as arthritis to depend heavily on over-the-counter pain reducers. The problem is they do not have the same potency as opioids. As a result, many, especially seniors, are taking much more acetaminophen (Tylenol) than recommended to control discomfort and pain."
"Drugs like ibuprofen (NSAIDS) are much more effective in controlling arthritic pain than acetaminophen, but not as safe," continued Attorney Connelly. "In fact, it is contraindicated in those with heart disease, leaving them with acetaminophen as the only available option."
"Before we begin our discussion, remember this, taken as directed and without alcohol, acetaminophen is better for your heart than ibuprofen products. However, this is a general statement; each person should check with their medical provider regarding acetaminophen or any over-the-counter product."
The Concerns with Acetaminophen (Tylenol)
"As I stated, taken as directed, acetaminophen (Tylenol) is a relatively safe over-the-counter medication," said Attorney Connelly. "However, there are increasing concerns among many geriatricians about the damage caused by the misuse and overuse of acetaminophen to address acute and chronic pain. As stated earlier, these concerns result from the opioid epidemic and the medical profession's reluctance to now prescribe narcotic medications for appropriate pain control."
A senior's slower metabolism results in the inability to clear medications as quickly as a younger person's system, which can lead to toxicity and even overdose with certain medications. This is due to physical changes as we age, including a reduction in muscle mass, more fat tissue, changes in body composition, and less fluid in the body systems. As a result, our body reacts differently to medications that it could previously metabolize without adverse reactions. Acetaminophen is one of these medications; the result can be life-threatening in some cases.
Manny lived alone in the Hyde Park neighborhood of Boston. At 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 told me. "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 worked through the system, I would reach retirement age, so I just took early retirement."
For years, Manny took 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 little to help my pain, especially in the wintertime when 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 and helped me sleep."
As stated, his doctor had discussed the opioid epidemic with him and the dangers of addiction, but he did not discuss 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. As time passed, 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 deep brown. "When I got up that day, 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 Massachusetts 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 if I stopped drinking and using [acetaminophen]."
"My question to my doctor was why he didn't warn me about these dangers. I shouldn't have drunk alcohol while taking these, but what was I to do for the pain? He worried about addiction, but I almost killed myself with over-the-counter medicine. Where's the common sense here?"
The Liver and Acetaminophen
When taking the recommended dose of acetaminophen, it is initially broken down in the gastrointestinal tract and then absorbed by the bloodstream. Usually, this takes about 45 minutes, and for older adults who may be taking suppositories, it takes up to two hours. Then, it is metabolized by the liver to be excreted in the urine. But taking too much acetaminophen can change how 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.
Typically, the liver can effectively clear tiny amounts of NAPQI, but more significant amounts kill cells and cause irreversible tissue damage. In severe cases, it can cause liver failure leading to biological 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 a liver transplant experienced multiple problems due to the long-term damage.
Here is another shocking statistic: those who take acetaminophen over several days at just 25 percent above the recommended dosage have been shown to experience liver damage. The guidance on acetaminophen dosing states that individuals should not take more than 4000 milligrams (mg) daily (with 3000 mg as the recommended ceiling).
Further, 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 the liver being damaged. The report also states that even when acetaminophen is discontinued, the damaging effects continue for several more days.
For those who may be prescribed a narcotic like hydrocodone or codeine, using acetaminophen to address breakthrough pain increases the chances of a toxic reaction. 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. Further, over half of acute liver failure cases in the United States result from acetaminophen overdose.
Alcohol Use and Acetaminophen
Chronic alcohol use combined with acetaminophen can increase the dangers of liver damage and stomach bleeding. As pointed out earlier, either one of these substances can cause liver damage by itself but combined with alcohol, the damage ranges from minor to highly 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 their 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 regularly."
The Stomach and Acetaminophen
A person who uses acetaminophen regularly at doses greater than 2000 mg. faces a four times greater chance of stomach bleeding in the upper gastrointestinal tract than those who don't. According to a blog on the Kressler Institute site, elevated levels of acetaminophen that cause damage to the liver release 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; in some cases, these bacteria are resistant to antibiotics.
The Heart, Kidneys, and Blood
Heavy use of acetaminophen has been associated with a 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. 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 types of blood cancers, including myeloid neoplasms, non-Hodgkin lymphomas, and plasma cell disorders like multiple myeloma.
Other Effects of Acetaminophen
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 reaction to other drugs present - often antibiotics or anticonvulsants). Exactly how acetaminophen causes these reactions is still in question, but it's essential to keep it in mind. Finally, in another study, researchers found a slightly elevated stroke risk in those with diabetes who used acetaminophen regularly.
In an Ohio State University study, it appeared that acetaminophen could affect emotional processing. According to researchers, those using acetaminophen regularly “evaluated unpleasant stimuli less negatively and pleasant stimuli less positively, compared with participants who took a placebo.” Both negative and positive events were less emotionally stimulating to those taking acetaminophen, blunting reaction to such events.
Another double-blind study by another research group at Ohio State found that acetaminophen users exhibited less empathy toward others' pain after taking the medication. The results of this study raised questions about the social implications of long-term acetaminophen use.
Acetaminophen in Disguise
Acetaminophen may also be contained in other OTC and prescription medications without the user knowing this. Cold medications such as Theraflu and Sudafed and several allergy medications have acetaminophen as an ingredient.
"Older individuals taking Tylenol for arthritis combined with Nyquil for a cold do so without realizing the cold medication also contains acetaminophen, and they may be doubling their dose without even realizing it," said Attorney Connelly. "It's important to read the label on any OTC medication you take." 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 must be asked of the pharmacist or your health provider."
"As we pointed out earlier, medical professionals say acetaminophen products are relatively safe when taking the recommended dosage and without using alcohol," continued Attorney Connelly. "Providers say that the recommended dosage for adults is between 650 mg and 1,000 mg of acetaminophen every 4 to 6 hours. 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 some other points to remember when taking acetaminophen products:
Don’t take Tylenol or acetaminophen products for more than ten 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 is 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 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 regularly, seek medical advice.
"As Americans age, 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 caused healthcare professionals to reduce prescribing stronger and more effective narcotic pain relievers. The result has been those with chronic pain issues, specifically older adults, seeking relief through OTC NSAIDs and acetaminophen. Because medication can be purchased over the counter does not mean it is safe. I can't stress this enough, always check with your healthcare provider."