Kurt Harris MD

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Tuesday
Jul072009

Acetaminophen and the War on Drugs

Many years ago after a surgical procedure I was given a prescription for Vicodin, which is the brand name combination of hydrocodone and acetaminophen. Hydrocodone is an opiate analgesic and acetaminophen is the generic name for tylenol. There was not (as still is not) a version of hydrocodone all by itself - you can only get the two in combination.

Now, the hepatotoxicity of acetaminophen was and is well known and currently some 38% of cases of acute liver failure are due to acetaminophen ingestion. You can get liver failure taking 15 extra strength tylenol a day or as little as 4 if you have liver damage from alcohol. I remember being annoyed that in order to get narcotic pain relief I was being forced to take a hepatotoxin that added little to the pain relieving efficacy of the opiate. I speculated to my wife that there were probably more injury and deaths occurring due to the acetaminophen than the "dangerous narcotic" in the Vicodin.

Now it looks like the FDA is starting to recognize the same thing that was obvious to a radiologist 10 years ago. It seems that as recreational drug users and addicts seek Vicodin for it's narcotic benefits, they are increasingly suffering inadvertent liver toxicity from the acetaminophen, contributing to the 40,000 ER visits per year related to acute liver injury.

Here is  story with a good summary.

There is a better review in the WSJ today but I can't link to it.

Tara Parker Pope of the NYT reassures us that acetaminophen is just fine. If you take her dietary advice, though, you probably already have metabolic syndrome. I am personally not so reassured that acetaminophen is safe as long as I don't take too much at once.

What has all this to do with the war on drugs? Well, in the early days of the misguided and counterproductive war on drugs, Richard Nixon signed the Drug Control Act that established "schedules" that doctors and patients must deal with today. The schedules range from IV to I, in order of their "abuse potential". Now, just so you don't get confused and think this had something to do with safety, chemotherapy agents, warfarin and other very dangerous drugs are not on the schedule, but pretty much any drug someone might take at a party is. It was decided that drugs should be made more difficult to obtain based on their potential for "abuse". In keeping with the moralistic and authoritarian origins of all this, "abuse" means "getting high" and has little to do with how dangerous the given drug was to your health. Some drugs, like cannabis, are schedule I and legally unavailable by anyone in most states. Does anyone think cannabis is deadlier than Jim Beam?

That is how you end up with unnecessary acetaminophen in your narcotic. The government figures it has a lower potential for abuse because you will be dissuaded from taking enough of it to "get high' by the potential for hepatotoxicity due to the added acetaminophen! The manufacturer responds to the incentives of the Drug Control act by adding the acetaminophen to get a schedule III classification. This makes it less onerous for the prescribing physician, and easier for the patient, resulting in greater sales for the drug company.

Make the potential party drug more toxic so it is less likely to be "abused".

In case you think my reasoning on this is overly cynical, have you ever purchased denatured alcohol at the hardware store? This is ethanol - the same kind found in your gin and tonic - which has been purposefully engineered to kill you if you drink it. "Denatured" implies there has been some chemical alteration of the alcohol, but in fact it is just intentionally contaminated with toxic solvents like methanol or acetone. The manufacturer goes to extra effort and expense to add poison with the sole purpose of escaping burdensome government regulation and taxation.

So I am glad the FDA is finally realizing what is going on, but it's too bad they don't address the true source of the problem, which is the war on drugs (the "schedule") and the perverse incentives such control attempts always create.

Your government is here to protect you from too much fun, even if it kills you.

 

PS Hydrocodone has its own toxicity issues, as Rush Limbaugh will attest.

I advise requesting pure oxycodone or maybe percodan postoperatively until they take the acetaminophen out of the Vicodin. I also don't advise taking any drugs for recreation.

hydocodone toxicity

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Reader Comments (8)

Then there's the interesting fact that NSAIDs are prescribed as prevention for inflammation-mediated disorders. They basically block the downstream effects of an omega-6:3 imbalance by blocking cyclooxygenase. Cardiologists generally accept aspirin, but they don't accept the implication that it's a (rather ineffective) band-aid placed over a problem caused by excess industrial vegetable oils. Of course, using COX blockers acute inflammation caused by tissue injury or infection is a different matter.

Interestingly, COX-2 blockers prevent most of the manifestations of metabolic syndrome in rats fed vegetable oils and sucrose, suggesting that omega-3/6 derived eicosanoids mediate its development.

I agree that the term "denatured alcohol" is a bit of a misnomer. I remember puzzling over how one could denature C-C-OH when I was in chemistry class, until I learned that means they just add poison to it.

Good post.

July 7, 2009 | Unregistered CommenterStephan

Kurt,

Thanks for the post, very interesting. Although I don't use acetaminophen often, I guess I do use it a bit too casually. Are there analogous hazards when using ibuprofen?

Mark

July 8, 2009 | Unregistered CommenterMark

Hello Mark

If you are otherwise healthy, one tylenol or 200mg ibuprofen or an aspririn once in a while are not going to hurt you.

With ibuprofen, you are trading liver effects for a risk of kidney toxicity - escpecially if you are dehydrated.

There are also some suggestive observational studies (not proof) that chronic use of acetaminophen and NSAIDs like ibuprofen may cause permanent kidney damage as well by affecting blood flow and causing papillary necrosis.

It's safest just to suck it up, but I find a single generic enteric-coated aspirin (325 mg) is pretty effective and safest for your liver and your kidneys.

I find since going low carb and grain free, my sinus heaaches and such have disappeared and I rarely take pain medication of any kind ( even though I am pushing 50)

July 8, 2009 | Unregistered CommenterKGH

Doesn't Percocet also contain acetominophen?

July 8, 2009 | Unregistered CommenterJen

Jen

My mistake

You can see I am not a druggie I guess! Yes percocet has acetaminophen. Oxycodone can be had alone
and that is what I recommend if you need narcotics. The reference I got that from was in error.

Oxyfast is pure oxycodone. Percodan has aspirin instead of acetaminophen.

July 8, 2009 | Unregistered CommenterKurt G. Harris MD

Just found your blog through Free the Animal. My own Tylenol horror story happened a few years ago when I got a fever, aches, and chills that wouldn't go away. On my second trip to the doctor I was advised to take extra-strength Tylenol to control the fever spikes. The maximum daily dose was 8 per day; I was taking 6. I was also eating a really crappy diet because I was too sick to cook and my husband can't, so I was eating a lot more carbs all of a sudden while I was sick. (That was before I knew how bad carbs are, and thought you just did low-carb for weight loss.) On my next doctor visit blood tests were ordered to look into the persistent fever. Everything tested for came back ok, except liver enzymes 10 times above normal. I was moved on to a gastroenterologist to investigate liver issues further. He tested for autoimmune hepatitis, and got a positive. He said it could be a false positive, but I had to have a liver biopsy to be sure. I asked for a best two out of three blood tests to see if they all came back positive, but was told I had to have a biopsy. The radiologist missed my liver (for real!) the first time, so I had to have a second biopsy. By this time I was back on a healthy low-carb diet and my fever had gone away. My liver was completely fine. That was quite a dog and pony show to find out I had a healthy liver. Needless to say, no more acetominophen for me and commitment for life to a regular real-food diet of about 60% fat, 30% protein, and 10% carbs.

July 9, 2009 | Unregistered Commenterethyl d

What do you recommend for period pain? I have eaten low carb for years; do not eat gluten, damaged fats, vegetable oils or any of that stuff. Yet, while other areas of my health have improved dramatically; I still get very bad cramps.

After reading this; can you tell me which painkiller is the safest for menstrual cramps?

October 23, 2009 | Unregistered CommenterLynn

my mom was as emergency room nurse and an icu room nurse. she saw that overdoses from aspirin ddn't have to be life threatening, while overdosing on acetaminiophen caused severe liver damage/death. she never gave us tylenol as kids, and she told me not to give it to my kids. every time i'd go to the pediatrician and answer that i gave my child aspirin, i got the tylenol lecture. sometimes i lied and said i gave tylenol to avoid the feeling that child protective services were going to be called. a couple of times i did give tylenol to my kids. my mom had so much stuff right. she's always said whole milk is better, and even wanted raw milk, which is illegal in nj. she always told us to build up a tan slowly and that we needed the sun. i'm lucky to have her as a mom. she didn't get everything right, however, as she has cancer, diabetes and heart disease right now. she was my inspiration to search out a better way, and that is why i am here to learn.

December 30, 2009 | Unregistered Commenterv
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