A new scare?

June 30, 2009 3:26 PM

You may know it as acetaminophen, paracetamol, APAP, or ... Tylenol. Today an FDA advisory panel recommended banning prescription drugs that contain acetaminophen, such as vicodin and percocet. The panel of experts also voted to give acetaminophen a black box warning, and reduce the maximum dosage of over-the-counter formulations. Acetaminophen is a popular painkiller by itself and, in combination with opiates, is the most commonly prescribed medication in the US.

Acetaminophen has known for over a hundred years, though its use in the US began in 1955. The brand has survived scares and maintained its popularity for decades, thanks to some innovative marketing (last link is a pdf) and effective analgesia in many clinical settings.

Acetaminophen is generally better tolerated than ibuprofen and other painkillers, but it's not without adverse effects -- acetaminophen is now the leading cause of liver failure in the US. The FDA panel hopes these measures will reduce overdoses leading to fulminant liver failure, but similar restrictions in the UK have had mixed results.

posted by borborygmi (117 comments total)

Sweeeet - my medicine cabinet's gonna be worth a ton in a few months.
posted by inigo2 at 3:28 PM on June 30, 2009 [3 favorites]

Funny, a friend of mine just noticed that and wrote about it today:

As an aside, there has been some news in the press recently about acetaminophen (tylenol). Evidently, it is the #1 cause of acute liver failure in the US with about 56,000 cases each year. Most of the cases seem to occur because people combine medications and don't realize that they are exceeding the recommended maximum daily dose of acetaminophen (4 grams). This was interesting because the medication I was taking for pain contained 325 mg of acetaminophen, and at recommended dosing I was getting 3900 mg of acetaminophen per day. If I had taken any extra tylenol, I would have exceeded the 4 gram per day limit.

posted by mathowie at 3:32 PM on June 30, 2009

Also, I know a ton of people who down vicodin with tylenol on the regular and that can't be good for your liver.
posted by empath at 3:34 PM on June 30, 2009

err-- vicodin with ALCOHOL
posted by empath at 3:35 PM on June 30, 2009

Before people start screaming too loud, this does not actually ban Tylenol, move Tylenol behind the counter, or put tiny transmitters in each caplet.
posted by StrikeTheViol at 3:35 PM on June 30, 2009 [6 favorites]

So that's why I was forced to stop abusing Vicodin because it gave me horrendous stomach pains--acetaminophen!!!! You bastard get out of my opiates!
posted by Liquidwolf at 3:37 PM on June 30, 2009 [2 favorites]

put tiny transmitters in each caplet

I'm pretty sure socialized health care does though, right?
posted by Mikey-San at 3:38 PM on June 30, 2009

Before people start screaming too loud, this does not actually ban Tylenol, move Tylenol behind the counter, or put tiny transmitters in each caplet.

What's that? I didn't hear you with all the HOLY FUCKING SHIT THEY ARE BANNING TYLENOL AND PUTTING TINY TRANSMITTERS IN EACH CAPLET AND FORCING EVERYONE TO TAKE TYLENOL AND BLACK VANS OH FUCK!
posted by Krrrlson at 3:38 PM on June 30, 2009 [10 favorites]

Great news. I prefer my opiates straight up -- the acetaminophen just makes you sick (though there is a way to separate out the two, it's a hassle.)
posted by Bron at 3:39 PM on June 30, 2009 [2 favorites]

It makes sense to me -- if it's sort of a "hidden" ingredient in a lot of pain pills (I have never thought of vicodin as an acetaminophen drug!), then it makes most sense to take it out and prescribe just that ingredient alongside, rather than combining it into one pill.
posted by hippybear at 3:39 PM on June 30, 2009

Also, I know a ton of people who down vicodin with tylenol on the regular and that can't be good for your liver.

uh... that's going to be a problem.

Anyway, amidst all those cold & flu remedies there are only about 4-5 active ingredients for OTC medicines. Un-bundling them actually sounds like a pretty reasonable idea.

From the top of my head

- pain killer / fever reducer: aspirin, acetaminophen and ibuprofen. (sodium naproxen only seems to get sold as back pain medicine)
- decongestant - pseudoepinephrine (sp?) or the new stuff that's no good
- antihistamine - either old-school benadryl or one of the fancy new non-drowsy ones - this is probably the only palce where there's an actual variation
- expectorant - gufansenin which may not even do anything
- caffeine for headache remedies

I prefer to buy them separately and take the specific stuff as needed. And I refuse to buy the crappy new decongestant on the principle that it doesn't work.
posted by GuyZero at 3:41 PM on June 30, 2009 [12 favorites]

Well, that's good. It will certainly reduce harm for those misusing pure opioids-- aka Vicodin or percoset *without* the acetaminophen-- because they won't be risking liver damage when they exceed the prescribed dose and that will give them a chance to have a healthy recovery.

What's sad is that people tend to think that the opioid is what's most dangerous in those drugs-- while you certainly *can* overdose on opioids and can become physically dependent and can become addicted, if you take as prescribed, the worst side effect is typically constipation.

If you do become an addict, overdose is rare if you don't mix with alcohol or benzodiazepines or suddenly start taking again after quitting. And, there's an antidote to overdose which could reduce even those deaths.

Acetaminophen, OTOH, if you take more than a certain amount, it will damage your liver irreversibly.
posted by Maias at 3:41 PM on June 30, 2009 [7 favorites]

The big problem with this is that acetaminophen is extraordinarily safe. Apart from overdose, it basically has no side effects. Even counting overdose, it's still one of the safest drugs there is. Roughly half of the acetaminophen-associated liver failures were associated with intentional overdose. Compared to the several billion doses consumed each year in the US alone the rate of liver failure is pretty low. So I think the problem is probably better addressed with the British approach: start selling acetaminophen in low count blister packs instead of 500 count bottles. If the rate of unintentional overdose is still too high then more drastic measures could be taken.

Also, the main reason that those prescription drugs have the acetaminophen built into them in the first place is to reduce the chance of people abusing the narcotic. So it's quite possible that removing the acetaminophen will result in the prescription of pure hydrocodone, oxycodone, etc, leading to an increase in prescription drug abuse and diversion and narcotic overdose. Or, it could also be that doctors, fearing just that, will be wary of prescribing adequate pain medication. The unintended consequences could be pretty bad.

In the end it may not make much difference. Acetaminophen will still be over the counter, so even with a reduced per-dose maximum people can still take too many and get sick.
posted by jedicus at 3:42 PM on June 30, 2009 [4 favorites]

First they came for my Phenylpropanolamine. But I said nothing because my NyQuil tasted better without it.

Then they came for my ephedrine. But I said nothing because my Starbucks Tylenol Mocha Latte is more powerful than heroin.

Then they came for my Starbucks Tylenol Mocha Latte....

Shoot. Who needs a liver, anyway?
posted by zarq at 3:42 PM on June 30, 2009 [6 favorites]

The panel ... said over-the-counter pain drugs and other medications containing acetaminophen should come in lower doses and that the highest dose currently on the market should only be available with a doctor's prescription.

See, this is what I don't get. One 500 mg Tylenol is the same as two 250 mg Tylenols. So what's the purpose of cutting the dosage? If I want to take a buttload of Tylenol I will just take more pills. (Same thing with the "prescription-strength" Advil they strip searched that girl for.)

Of course, people might not take fistfuls of Tylenol if they had legal access to more effective pain relief.
posted by vilthuril at 3:42 PM on June 30, 2009 [2 favorites]

I already have to take four just to get rid of a fucking headache.

Now when they reduce the amount in the pills I'm going to have to take, what, thirty?
posted by Malice at 3:42 PM on June 30, 2009 [1 favorite]

Why would you combine something that's so damaging to your liver with something that's so goddamn fun to take?
posted by empath at 3:44 PM on June 30, 2009

I forgot the cough suppressant, usually dextromethorphan.

We should totally go back to all-codine all the time.
posted by GuyZero at 3:44 PM on June 30, 2009

I already have to take four just to get rid of a fucking headache.

Now when they reduce the amount in the pills I'm going to have to take, what, thirty?

Are you talking about Vicodin or tylenol?
posted by empath at 3:45 PM on June 30, 2009

I'm pretty sure socialized health care does though, right?

Yeah, this is why our taxes are higher. Monitoring all those transmitters gets expensive, especially with a unionized, public sector workforce. On the other hand, in hospitals, we don't get charged $600 for nurse-administered painkillers, so it's kind of a wash.
posted by kowalski at 3:47 PM on June 30, 2009 [1 favorite]

ok, which asshole at Big Pharma forgot to pay out the bribes this month? Seriously, people, get on the fucking ball, here.
posted by shmegegge at 3:48 PM on June 30, 2009 [9 favorites]

And, there's an antidote to [narcotic] overdose which could reduce even those deaths.
Acetaminophen, OTOH, if you take more than a certain amount, it will damage your liver irreversibly.

In fact there's an effective antidote (acetylcysteine) for acetaminophen overdose if it's caught early enough. In untreated cases, if the victim survives, liver function usually returns to normal after a while. Irreversible damage is rare.

I already have to take four just to get rid of a fucking headache.

If you're talking about 500mg extra strength acetaminophen, then you should not take more than two. 1000mg is the therapeutic maximum for almost all people, and taking more does not produce better results. If necessary, acetaminophen can be combined with an NSAID like ibuprofen as the mechanism of action is different and the analgesic effects somewhat additive. If appropriate doses of over the counter medications aren't controlling your headaches, you should consult a doctor.
posted by jedicus at 3:49 PM on June 30, 2009 [1 favorite]

Does this also apply to children's Tylenol?

WON'T SOMEONE THINK OF THE CHILDREN!?!?
posted by clearly at 3:50 PM on June 30, 2009 [2 favorites]

"Also, the main reason that those prescription drugs have the acetaminophen built into them in the first place is to reduce the chance of people abusing the narcotic. So it's quite possible that removing the acetaminophen will result in the prescription of pure hydrocodone, oxycodone, etc, leading to an increase in prescription drug abuse and diversion and narcotic overdose. Or, it could also be that doctors, fearing just that, will be wary of prescribing adequate pain medication. The unintended consequences could be pretty bad."

Surely there is some other adulterant they could use, preferably something that makes you puke, which doesn't cause long term damage.
posted by Mitheral at 3:51 PM on June 30, 2009

inigo2: "Sweeeet - my medicine cabinet's gonna be worth a ton in a few months."

honestly, if you can't get vicodin from your doctor, your doctor will just resort to prescribing something else that didn't used to be his go to "shut up and get out of my face" mother's-little-helper before. now, instead of everybody downing vicodin, it'll suddenly become much more common to see dilaudid moms or something. then, since the recreational pill poppers who DON'T have regular doctors as pushers (aka junkies, college kids, teenagers) just get whatever they can score, you'll see the same trend exhibited among those guys, too, as increased demand for other narcotc pain relievers switches which nasty opiate floods the street market.
posted by shmegegge at 3:53 PM on June 30, 2009

The headache pills in our work first-aid cabinest are aspirin, acetaminophen and caffeine - 65mg of caffeine!! If straight tylenol isn't cutting it, take a couple of those - they seel 'em as Tylenol EXTREME or something. Don't expect to get any rest that night though. But caffeine is a vasodialtor and often helps with headaches - unless it's a coffee withdrawal headache. In which case, tough nuts.
posted by GuyZero at 3:54 PM on June 30, 2009

Of course, people might not take fistfuls of Tylenol if they had legal access to more effective pain relief.

We're still not giving you "medical" marajuana, hippy. Last time we accepted that shady doctor's prescription, you toked it all in the parking lot, then came back to tell us that you figured out why M&Ms don't melt in your hand. Your brilliant deduction? Because you kept them in a bag when you weren't eating them.
posted by filthy light thief at 3:54 PM on June 30, 2009 [15 favorites]

Surely there is some other adulterant they could use, preferably something that makes you puke, which doesn't cause long term damage.

Are you kidding? Alcoholics will drink hand sanitizer because it may contain ethyl alcohol, and alcohol addiction isn't in the same league as narcotic addiction.

You could mix oxycodone into ipecac, and folks would still chug it - hell, if they knew they were going to just throw it up anyway, such folks would simply drink more to ensure a higher absorption rate. I can't wait to see the new "vomit comet" party trend.
posted by FormlessOne at 3:58 PM on June 30, 2009

Not to mention the party-crashers drinking the other peoples' vomit just to get a secondary high!
posted by jamstigator at 4:01 PM on June 30, 2009

Mmmm...secondary vomit high.
posted by jamstigator at 4:02 PM on June 30, 2009 [1 favorite]

We're still not giving you "medical" marajuana, hippy.

*pout*
posted by hippybear at 4:02 PM on June 30, 2009 [4 favorites]

Tylenol is insanely dangerous precisely because its toxic dose is so close to the recommended daily maximum - and nobody realizes it. People keep Tylenol within reach of children precisely because it's the "safe" painkiller you're allowed to give your kids - and teenagers reach for the Tylenol for cry-for-help suicide attempts for that very same reason. And then they die of liver failure, or at least suffer permanent damage, from taking 20 pills.

56,000 cases of liver failure due to Tylenol a year is a massive and disgraceful number. How many people die from heroin a year? Cocaine? E? Marijuana? Cars?
posted by mek at 4:08 PM on June 30, 2009 [5 favorites]

Surely there is some other adulterant they could use, preferably something that makes you puke, which doesn't cause long term damage.

What a great way to punish people who have been correctly prescribed much-needed pain meds, while not preventing desperate addicts from abusing these drugs anyhow.
posted by Sticherbeast at 4:09 PM on June 30, 2009 [5 favorites]

Are you kidding? Alcoholics will drink hand sanitizer because it may contain ethyl alcohol, and alcohol addiction isn't in the same league as narcotic addiction.

This is either a qualitative judgement or completely false. Alcoholics will DIE if they go cold turkey.
posted by mek at 4:10 PM on June 30, 2009 [1 favorite]

The headache pills in our work first-aid cabinest are aspirin, acetaminophen and caffeine - 65mg of caffeine!! [....] Don't expect to get any rest that night though.

Eh, a cup of coffee runs 100-200 mg of caffeine, so it's not as though you're ingesting some Herculean quantity of caffeine by taking a couple pills. Maybe taking it in pill form rather than hot beverage form makes it hit you harder, but that seems like a bit of a stretch.
posted by letourneau at 4:10 PM on June 30, 2009

Also, the main reason that those prescription drugs have the acetaminophen built into them in the first place is to reduce the chance of people abusing the narcotic. So it's quite possible that removing the acetaminophen will result in the prescription of pure hydrocodone, oxycodone, etc, leading to an increase in prescription drug abuse and diversion and narcotic overdose. Or, it could also be that doctors, fearing just that, will be wary of prescribing adequate pain medication. The unintended consequences could be pretty bad.

This is hardly an effective way of fighting addiction-- and is actually not true as far as I know. Do you have any citation to support this?

For one, most addicts don't know the stuff is there-- and secondly, the public campaigns are about scaring them about the evil opioid, not about the danger from acetaminophen. I've never seen a DARE book or PSA saying "Don't take extra Vicodin-- or the TYLENOL in it will kill you!"

Third, addiction is defined as compulsive use *despite* negative consequences, so who decided it was a good idea to make one of these consequences liver damage that no one knows could occur anyway?

Fourth, it's an insanely expensive negative consequence-- let's make people need liver transplants, great idea dudes!!! Of course, stupidity has never stopped bad drug policy before, but I don't think this was ever a deliberate strategy and if it was, it was an evil and ill-advised one.

Kind of like, let's not give them clean needles in hopes that AIDS will deter them. Oops, all that got us was a heterosexual and pediatric AIDS epidemic, brilliant idea guys!!
posted by Maias at 4:11 PM on June 30, 2009 [14 favorites]

jedicus makes a good point: really a lot of tylenol overdoses are at least semi-intentional. Unfortunately, it is a drug of choice for kids making suicide attempts intended mainly as a gesture. Most of them have no idea that a medication that seems so benign, a medication they've taken all their lives and that sits in the medicine cabinet unmonitored, can actually hurt them when taken in quantities not all that much larger than the recommended dose.
posted by timeo danaos at 4:13 PM on June 30, 2009

Prescription painkillers that include acetaminophen should be pulled from the U.S. market because they can make it too easy for patients to overdose

I thought that was the point. There's not really a good medical reason to include the acetaminophen in the pill. If you're knocking back ten milligrams of hydrocodone, 500 mg of acetaminophen is probably not going to make that much difference in your net pain relief. But even if it does, you could just as easily take the acetaminophen seperately, as it costs about four bucks for a whole bottle. No, the point of including that Aceta is to make it harder for people to get high. Or, more specifically, to make sure that someone who tries to take upwards of sixty or seventy milligrams of hydrocodone - say, a chronic abuser who has built up a tolerance - is likely to end up in the emergency room with liver failure.

Of course, they do sell opiates without the acetaminophen. The best known of them is probably Oxycontin. Doctors would rather cut off their mothers' hands and sell them on E-Bay than prescribe this stuff.

I take, on average, about one hydrocodone/acetaminophen dose a month, when I get one of my more severe headaches, which are connected to some other health problems I have. Much more frequently, I take regular OTC acetaminophen. I recently went to see a pain management doctor to get a prescription for the hydro. (That alone probably could have been done through a regular primary care doc, but there were other factors which made me want to go with the specialist). I explain to the pain management doc that I'm concerned about the amount of acetaminophen I'm taking overall and that one of my liver enzymes is elevated. I have an appointment with a liver specialist, but it's still several weeks away. Also, I've recently had a problem with ibuprofen causing stomach pain. So the doc doesn't want to prescribe me hydrocodone combined with either aceta or ibu. At the time, I assumed he'll just prescribe a non-combination form of hydro, not realizing that there's no such thing on the market. If you want an opiate that isn't mixed with something, you have to go up to the next level; Oxycontin. So, logically, he should prescribe Oxy at the rate of one per month. However, I'm a first time patient and he has the government watching him like a hawk. He could get in trouble. So, instead, he prescribes a Fentanyl patch. This, it turns out, is a major league opiate - some say on par with morphine. The fact that it is delivered transdermally presumably makes it less desirable to drug addicts. However, it's definitely more drug than I need. On top of that, the package insert carries a big, bold lettered warning which says Fentayl is only for people who are "opiate tolerant," which means people who regularly take 30 mg of Oxycontin a day, or more. If a non-tolerant individual were to take Fentanyl, s/he'd risk "hypo-ventilation," which is a fancy way of saying "not breathing enough." Needless to say, I didn't use the Fentanyl patch. Oh, and then, as an added bonus, I later found out that there have been recalls on this product; sometimes it leaks and delivers too much drug at one time, resulting in death and other unpleasantries.

The point here is that this policy of selling hydrocodone only in combination with ibuprofen and acetaminophen may reduce the number of people taking it to get high, but it's fucked up in a number of other ways.

Also, is it really ethical to poison - or threaten to poison - drug addicts?
posted by Clay201 at 4:14 PM on June 30, 2009 [11 favorites]

mek: "Are you kidding? Alcoholics will drink hand sanitizer because it may contain ethyl alcohol, and alcohol addiction isn't in the same league as narcotic addiction.

This is either a qualitative judgement or completely false. Alcoholics will DIE if they go cold turkey."

it is neither. also, not all alcoholics will die if they go cold turkey. alcohol addiction, at its highest levels, is a very problematic addiction to rid yourself of. there's no denying that. but the people you're thinking of who routinely DIE if they go cold turkey are the narcotic addicts. hardcore alcoholics, though every case varies, often go cold turkey. and while some are badly addicted enough that cold turkey is not a feasible option, it takes much more alcohol for a much longer time to reach that level of addiction, and the chemical dependency is often a little lower for alcoholics.

but I'm not giving you statistics for a reason. levels of addiction, and the difficulty in kicking, are pretty subjective things. but for real, narcotic addiction is another thing altogether. people go on non-narcotic chemical substitutes for their entire lives to get off and stay off of narcotics.
posted by shmegegge at 4:16 PM on June 30, 2009 [1 favorite]

Of course, they do sell opiates without the acetaminophen. The best known of them is probably Oxycontin. Doctors would rather cut off their mothers' hands and sell them on E-Bay than prescribe this stuff.

Really? Seems like my mother is having oxycontin forced into her face every time she goes to a new specialist about her scoliosis. It's the first thing they offer her. She has even joked with me about how she should take the scrips and sell the pills on the street and fund her and my father's next vacation. (She's not doing that. Back off, Total Information Awareness.)

Also, is it really ethical to poison - or threaten to poison - drug addicts?

It is here in the USA, because drug addicts are considered non-persons by the majority of the population.
posted by hippybear at 4:19 PM on June 30, 2009

I assume that means they'll switch to pure opiates, right? Since those won't cause (as much?) liver damage.

Oh wait no that would be morally wrong, so we'll just have to let people suffer. It's for their own good of course. builds character.
posted by delmoi at 4:24 PM on June 30, 2009

shmegegge: I don't think we need to derail this thread with your personal opinions on alcohol addiction vis-a-vis other narcotic addictions: I will finish by noting that alcohol is a drug like any other. Oh, and I didn't notice you giving any statistics at all - just sweeping generalizations grounded by nothing.
posted by mek at 4:26 PM on June 30, 2009

but the people you're thinking of who routinely DIE if they go cold turkey are the narcotic addicts.

Do you have statistics on this? I thought the reverse is true, that alcohol withdrawal is more lethal then opiate withdrawal, but I'm not sure.
posted by delmoi at 4:26 PM on June 30, 2009

This is a good thing. I've noticed from just casual observation that people tend to overdo the Tylenol thing without keeping track of how much they're actually putting into their bodies. There's a bit too much trust in the drug.
posted by spiderskull at 4:27 PM on June 30, 2009

ok, which asshole at Big Pharma forgot to pay out the bribes this month? Seriously, people, get on the fucking ball, here.

You're not thinking very clearly. They'll replace the acetaminophen with some new-fanged chemical that has the same safety feature (will make you throw up if you take too much) but without the liver damage. And whoever comes up with it and patents it will make a fortune, as opposed to what they get for long-unpatented acetaminophen with codeine.
posted by delmoi at 4:30 PM on June 30, 2009 [1 favorite]

... You assholes at the FDA can take my vicodin from my cold dead hands or when you give me a substitute that works as well for pain.

Until then you keep this crap on the market, and when you have a safe alternative that idiots don't poison themselves with THEN you take it off.

I'm sorry, but as someone with a chronic pain condition whose life routinely becomes unlivable without opiate painkillers of these types, even the THOUGHT of going back to life without having them available is enough to make me violently angry.
posted by strixus at 4:32 PM on June 30, 2009 [5 favorites]

So I think the problem is probably better addressed with the British approach

I think the problem is best addressed using the Mexican approach: Sell people what they want and if they're too dumb to research their medications or read a label, they'll die of liver failure.

450 deaths per year isn't that many, considering the billions of pills sold. If cars had that level of safety, we'd have 1 automobile-related fatality every few years.
posted by coolguymichael at 4:32 PM on June 30, 2009 [1 favorite]

Honestly if the root cause of this set of measures is because people were too stupid to not read the labels that are on any medication they take, and thus fail to notice that they are taking excess acetaminophen, then it's overkill.

They should recommend an education campaign, but otherwise it's borderline nanny state tactics since, at currently allowed maximum dosage levels, acetaminophen is safe.

Seriously, if I've got a cold and take Dayquil, I read the label and thus know that it contains acetaminophen, so I don't take an extra dose for my fever, because I've already taken one. It's not difficult at all.
posted by cmgonzalez at 4:35 PM on June 30, 2009

From the first link:

Acetaminophen use is the leading cause of acute liver failure in the 1,600 cases seen each year in the United States, according to a 2007 Centers for Disease Control and Prevention estimate.

Not to contradict Mathowie's friend, but that seems somewhat lower than 56,000 cases a year to me.
posted by darksasami at 4:35 PM on June 30, 2009

Alcoholics will DIE if they go cold turkey. Really? I thought they burst into flame without alcohol to dampen that fire inside their bellies.

Dark humor aside, wikipedia may have the answer, if you trust wikipedia. The US National Library of Medicine doesn't list death under "Severe symptoms," but I don't know if death is particularly a symptom, or side-effect.
posted by filthy light thief at 4:37 PM on June 30, 2009

FDA officials are concerned that warnings are not heeded by consumers and are looking for new ways to reduce the number of overdoses.

If warnings are not being heeded by consumers, it's not the government's job to ban the product.

Millions of people fail to heed the warnings on alcohol or tobacco products, but they're still legal. Or those who fail to heed the warnings on space heaters and sleep with them on or leave them unattended and cause fires. Or those who use their hair dryers near water.

The list goes on and on.
posted by cmgonzalez at 4:39 PM on June 30, 2009

FDA officials are concerned that warnings are not heeded by consumers and are looking for new ways to reduce the number of overdoses.

If warnings are not being heeded by consumers, it's not the government's job to ban the product.

Not certain anything is being banned here.
posted by hippybear at 4:42 PM on June 30, 2009

Did you even read the post, hippybear? Particularly the very first link in it? Or even just what the post says, which is a summary of that link.

The word "ban" is right there.
posted by cmgonzalez at 4:52 PM on June 30, 2009

To get more exact with the numbers, Tylenol is the leading cause of the 1,600 cases of acute liver failure per year in the USA, so the actual number is probably below 1000.
posted by mek at 4:54 PM on June 30, 2009

Here is what wikipedia actually says about Alchohol Withdrawl:

<sub>Alcohol withdrawal differs significantly from most other drugs in that it can be directly fatal. For example it is extremely rare for heroin withdrawal to be fatal. When people die from heroin or cocaine withdrawal they typically have serious underlying health problems which are made worse by the strain of acute withdrawal. An alcoholic, however, who has no serious health issues, has a significant risk of dying from the direct effects of withdrawal if it is not properly managed. Drugs which have a similar mechanism of action to alcohol also have a similar risk of causing death during withdrawal, including barbiturates and benzodiazepines.

Alcohol's primary effect is the increase in stimulation of the GABAA receptor, promoting central nervous system depression. With repeated heavy consumption of alcohol, these receptors are desensitized and reduced in number, resulting in tolerance and physical dependence. Thus when alcohol is stopped, especially abruptly, the person's nervous system suffers from uncontrolled synapse firing. This can result in symptoms that include anxiety, life threatening seizures, delirium tremens and hallucinations, shakes and possible heart failure.</sub>

So right, it is more lethal. According to Wikipedia.
posted by delmoi at 4:55 PM on June 30, 2009

I should have gotten a kickback from Purdue Pharma for all the rambling, highed up lectures about the evils of unnecessary APAP I gave to dudes who swore by Percs and Vikes back when I was hooked on Oxys.
posted by The Straightener at 4:55 PM on June 30, 2009

Sorry... I took "ban" to mean "remove from the market altogether". I was reading the article to say more that they were decoupling tylenol from other ingredients, not removing it from sale.
posted by hippybear at 4:55 PM on June 30, 2009

You assholes at the FDA can take my vicodin from my cold dead hands or when you give me a substitute that works as well for pain.

Until then you keep this crap on the market, and when you have a safe alternative that idiots don't poison themselves with THEN you take it off.

I'm sorry, but as someone with a chronic pain condition whose life routinely becomes unlivable without opiate painkillers of these types, even the THOUGHT of going back to life without having them available is enough to make me violently angry.

They're taking the tylenol out, not the opioid, so you should be fine. In fact, you will be at lower risk of liver damage. The idea is to get rid of the dangerous element, not the one that actually kills the pain... I wouldn't support this if it were getting rid of the opioid.
posted by Maias at 5:02 PM on June 30, 2009

mathowie: the 4g/day limit isn't a hard limit -- it's an approximation. The actual dose that will cause you to regret it varies depending on how well your liver functions. It also varies depending on how much paracetamol (US: acetaminophen) you take at one time. In general, a healthy adult should survive if they take 4000mg in one dose, and no more (before or after) for several hours. You should even be able to survive taking more than 4000mg in a 24 hour period if it's well spaced out.

Unfortunately, you have no way of knowing how well your liver is functioning, and one of the metabolites of this particular drug is a potent hepatotoxic agent. Take a small amount, and your liver can deal with it. Go over your personal threshold and you can cause serious liver damage without realizing it. If you're healthy, the danger dose is higher than 4g; if you've got underlying liver disease or undiagnosed Hepatitis, the danger dose can be much lower.

The UK had a big problem with paracetamol because it was available over the counter in supermarkets and shops as well as pharmacies. Idiot teens tended to use it for "cry for help" suicide attempts. What they didn't realize was that if you take 20-30 tablets, you won't lose consciousness or feel anything. You'll think nothing has happened ... until two or three days later, when you begin to feel ill (because you've just fried your liver and you're going to die, slowly and in pain).
posted by cstross at 5:02 PM on June 30, 2009

And yes, alcohol withdrawal and benzodiazepine withdrawal can be fatal without any underlying medical conditions, which is not true of opioid withdrawal.
posted by Maias at 5:03 PM on June 30, 2009

Maias, the reason the two are coupled is because the two together are more effective at dealing with some types of pain than JUST the opioid on its own. I've tried the straight opioid versions and they dope me up by far more while being far less effective on the pain type that I have.
posted by strixus at 5:12 PM on June 30, 2009

Me: ... Oxycontin. Doctors would rather cut off their mothers' hands and sell them on E-Bay than prescribe this stuff.

hippybear: Really? Seems like my mother is having oxycontin forced into her face every time she goes to a new specialist about her scoliosis. It's the first thing they offer her.

Me again: I've done very little reading on this subject, so I'm going mostly by my own impressions from having dealt with the medical establishement.

It seems to me that there are certain classes of patients who can get all the heavy duty pain killers they could ever want. Cancer patients leap immediately to mind, but I'm sure there are plenty of others, most with less lethal conditions. However, this classification system is not necessarily fair and might have more to do with the doctor being able to defend his/her decision in a malpractice case than with the facts and logic of a particular case.

Another facet of the issue; ghetto-ization. Pain management practices seem to exist - at least partially - so that all the risks and issues inherent to long term narcotic use can be kept in one sector, largely seperate from the rest of medicine. When you go to one of these clinics, they have you sign a form which says they can piss test you every time you visit and any other time they want., that you have to show them your bottle(s) of meds to prove that you've been taking the amounts you say you've been taking, that you promise not to get pain meds anywhere else, etc. Oh, and they have a shrink look you over pretty thoroughly to see whether you're an addict.

Of course, there are doctors outside of the pain management field who prescribe narcotics. However, even in these cases, the ghetto-ization persists. Like, you may see a neurologist about a painful condition, but discover that he just doesn't prescribe narcotics at all, ever. If he feels your case warrants it, he refers you to to a different neurologist, one who lets it be known that he does prescribe narcotics. Of course, this guy ends up with all patients in town who have severely painful neurological conditions. So again, it's contained in one sector.

My experience is that, once you gain entry to said sector, the pain meds flow pretty freely. But unless and until you do, they're guarded like Fort Knox and anyone who appears to be seeking them is regarded as suspect.
posted by Clay201 at 5:14 PM on June 30, 2009 [1 favorite]

56,000 cases of liver failure due to Tylenol a year is a massive and disgraceful number. How many people die from heroin a year? Cocaine? E? Marijuana? Cars?

Acetaminophen use is the leading cause of acute liver failure in the 1,600 cases seen each year in the United States, according to a 2007 Centers for Disease Control and Prevention estimate.

Tylenol: 56,000? 1,600? 1,000?

For the others, the following stats are from 2005. I saw some reports that suggest MDMA might be around 50, and I also saw marijuana as 0.

Heroin: 2,011
Cocaine: 6,228
Ecstasy/MDMA: no data
Marijuana (Cannabis poisoning): 112
Cars: 45,343

Clearly, we need to reduce the standard dosage of motor vehicle use.
posted by stopgap at 5:15 PM on June 30, 2009 [4 favorites]

Also, it is important for pain patients to be heard by the FDA about this: if they are thinking of pulling something like getting rid of Vicodin and Percoset *without* offering replacements without the acetaminophen that are the same level controlled substances, it would be very bad for pain patients.

There does appear to be a hydrocodone (Vicodin) which is schedule III and an oxycodone (percocet) with ibruprofen instead, which is schedule II, which would be existing options but schedule II's are more of a pain in the butt.
posted by Maias at 5:18 PM on June 30, 2009

Tylenol: now with Ipecac!

You'll never take too much again!
posted by bwg at 5:19 PM on June 30, 2009

Note: those cannabis numbers above have got to be "mentions"-- ie, in combination with other drugs, otherwise they'd be making medical history as the known fatal dose is not possible to consume in time to actually kill you.
posted by Maias at 5:20 PM on June 30, 2009 [2 favorites]

In related news, Flintstones vitamins taste delicious, also: poisonous.
posted by clearly at 5:21 PM on June 30, 2009

Maias, the reason the two are coupled is because the two together are more effective at dealing with some types of pain than JUST the opioid on its own. I've tried the straight opioid versions and they dope me up by far more while being far less effective on the pain type that I have.

IANAD, but that sounds like a dose issue because acetaminophen is not psychoactive and shouldn't affect the psychoactive effects of opioids.
posted by Maias at 5:22 PM on June 30, 2009

Clearly, we need to reduce the standard dosage of motor vehicle use.

Does this mean I have to stop running people over?
posted by clearly at 5:22 PM on June 30, 2009

You're very wrong about alcohol withdrawal, or that's what they told me in med school. It sucks when someone you admit for a pneumonia goes into DT.
posted by a robot made out of meat at 5:26 PM on June 30, 2009

If you want the effects of the opioid without the liver damage, try cold water extraction.

I have helped to treat a few acetaminophen overdoses (as an EMT). Rolling up on a scene and finding a big, empty bottle of Tylenol, or any NSAID is bad news. I wanted to put up billboards that say "you won't die right away, you will turn bright yellow and die slowly over the course of weeks."

As an aside, every emergency medical person has a plan for suicide. If you try to kill yourself, we will talk about you the whole way back to the station and then spend all night talking about how we would do it.

I didn't believe in any of these plans 'til a paramedic gave himself an antifreeze IV after an unhappy love affair. Ugh.

In brighter news, look up the "drop test" for a laugh. OK, maybe that is a dark laugh.
posted by poe at 5:34 PM on June 30, 2009 [5 favorites]

I take Hydrocodone w/ 325mg APAP for my migraine headaches. I regularly remove the acetaminophen when I need to take more that one pill for the pain.
posted by brevator at 5:49 PM on June 30, 2009

Cannabis poisoning?! Must be people with an allergy, because I and many others I know have smoked pot virtually nonstop for days at a time, along with eating a goodly chunk of brownies. Do you have to build your home out of cannibis, climb into bed, then set your house on fire, to experience cannabis poisoning? Gotta be an allergy, or else these people are seriously committed to purposely dying from pot, because I just don't see any other way it could happen.
posted by jamstigator at 5:51 PM on June 30, 2009 [3 favorites]

Anyway, amidst all those cold & flu remedies there are only about 4-5 active ingredients for OTC medicines. =

- pain killer / fever reducer: aspirin, acetaminophen and ibuprofen. (sodium naproxen only seems to get sold as back pain medicine)
- decongestant - pseudoepinephrine (sp?) or the new stuff that's no good
- antihistamine - either old-school benadryl or one of the fancy new non-drowsy ones - this is probably the only palce where there's an actual variation
- expectorant - gufansenin which may not even do anything
- caffeine for headache remedies



Tylenol PM is just acetaminophen and "sudafed".

"Non-drowsy" antihistamine is just an antihistamine cut with speed to counteract the drowsy effect of the antihistamine.
posted by Zambrano at 5:56 PM on June 30, 2009

[Combining acetaminophen and opioids] is hardly an effective way of fighting addiction-- and is actually not true as far as I know. Do you have any citation to support this?

Well, the Wikipedia article on hydrocodone mentions it, but doesn't provide a cite. I can offer this patent on a combination of an opioid and acetaminophen intended to reduce abuse potential. Whether it's actually a good idea from a harm reduction or abuse prevention standpoint is another matter.

So, instead, he prescribes a Fentanyl patch. This, it turns out, is a major league opiate - some say on par with morphine.

Not on par with, vastly (~100x) more powerful than morphine by weight. Fentanyl is dosed in micrograms.
posted by jedicus at 5:59 PM on June 30, 2009

According to Penn and tellers how to play with your food there's a chemical in listerine that induces vomiting when consumed in large quantities. Apparently to prevent alcoholics from chugging the stuff. Good for practical jokes and maybe cutting opiates?
posted by cloax at 6:05 PM on June 30, 2009

Tylenol PM is just acetaminophen and "sudafed".

Tylenol PM is acetaminophen and "Benedryl" (diphenhydramine). And Johnson & Johnson has been very irresponsible in promoting it primarily as a sleep aid. Diphenhydramine alone is what most OTC sleeping pills contain, and there is absolutely no need to couple it with acetaminophen if you are not in pain and just want to sleep. They really shouldn't be getting away with that.
posted by kamikazegopher at 6:05 PM on June 30, 2009 [2 favorites]

Also, it is important for pain patients to be heard by the FDA about this: if they are thinking of pulling something like getting rid of Vicodin and Percoset *without* offering replacements without the acetaminophen that are the same level controlled substances, it would be very bad for pain patients.

There does appear to be a hydrocodone (Vicodin) which is schedule III and an oxycodone (percocet) with ibruprofen instead, which is schedule II, which would be existing options but schedule II's are more of a pain in the butt.

I just read a bit about that. From here:

In a far less decisive vote, the committee voted 20 to 17 in favor of a more extreme recommendation to pull all prescription products containing acetaminophen from the market.

Because the split was so close, it is unclear whether the FDA will adopt the recommendation, but if it did, some options would be eliminated for pain patients. For instance, patients taking Vicodin would not have an acetaminophen-free option because there is no hydrocodone-only formula.

In addition, removing the acetaminophen from the Vicodin would move the drug into the more-strictly regulated "class II" schedule of narcotics from its current classification as a class III drug, creating additional barriers for physicians prescribing the drug to patients.

That makes me think it's unlikely the FDA will ban them. The outcry would be too great.
posted by homunculus at 6:06 PM on June 30, 2009

"Non-drowsy" antihistamine is just an antihistamine cut with speed to counteract the drowsy effect of the antihistamine.

What? No. diphenhydramine is the classic sleep-inducing antihistamine but stuff like Claritin (Loratadine) or Allegra (fexofenadine) are completely different. Claritin-D is just the antihistamine plus pseudoephedrine which is why you have to ask the pharmacist for it. But for some reason you don't see those combined with acetaminophen like you do with diphenhydramine.

The idea that Claritin = diphenhydramine + speed is pretty bizarre.
posted by GuyZero at 6:12 PM on June 30, 2009 [2 favorites]

shmegegge: I don't think we need to derail this thread with your personal opinions on alcohol addiction vis-a-vis other narcotic addictions: I will finish by noting that alcohol is a drug like any other. Oh, and I didn't notice you giving any statistics at all - just sweeping generalizations grounded by nothing.

hey thanks, that's awfully big of you. I also appreciate you doing it so nicely. It's a really nice change of pace when people can just drop a subject without trying to get in any sort of obnoxious last word.
posted by shmegegge at 6:27 PM on June 30, 2009 [1 favorite]

From when I taught toxicology (about seven years back), acetaminophen was the number one drug overdose in emergency rooms, followed by aspirin and then morphine. Of course that's also because the first two are common and available.

Also zambrano: "Tylenol PM is just acetaminophen and "sudafed". "Non-drowsy" antihistamine is just an antihistamine cut with speed to counteract the drowsy effect of the antihistamine."

Tylenol PM is a acetaminophen plus an antihistamine. And, as was pointed out, the non-drowsy antihistamines can be a variety of drugs without a stimulant. The D in Claritin D is Claritin plus a decongestant, an alpha stimulant, related to speed, but still far from it.
posted by dances_with_sneetches at 6:29 PM on June 30, 2009

expectorant - gufansenin which may not even do anything

Really? That surprises me, because it always turns unpleasant, thick mucous into nice, runny mucous for me. If it isn't an active ingredient, then it's having one helluva impressive placebo effect on me; there's nothing else in Robitussin afaik, other than sugar, colour, and filler.
posted by five fresh fish at 6:41 PM on June 30, 2009 [1 favorite]

Jesus people, read the link. The cannabis number is "mentions", just as Maias supposed. It's all in the caption under the chart the number is taken from:

NOTES: Substance-specific data are not additive because a death certificate could have multiple drugs listed. ICD is International Classification of Diseases. Poisoning deaths for Opium (ICD-10 T40.0), LSD (ICD-10 T40.8), and Other and unspecified psychodysleptics (ICD-10 T40.9) are not shown separately because there were fewer than 10 deaths in any year.

SOURCE: CDC/NCHS, National Vital Statistics System.

My psychopharmacology text has a short passage ranting about the NCHS drug hospitalization and death "mentions" as being a statistic that is intentionally designed to overstate the dangers of illegal drugs, especially drugs frequently consumed with other drugs, such as cannabis and cocaine; of course, this renders it completely useless to reality-based epidemiology.
posted by [expletive deleted] at 6:41 PM on June 30, 2009 [1 favorite]

Or... you could just mandate that all paracetemol be combined with a sufficient dose of methionine to replenish the liver's glutathione levels and so lower the probability of a runaway toxic fulmination. This would of course make the pills more expensive to manufacture so that's not really going to happen. The argument against it, using the high NNT of 999 people who would be pre-treated with methionine so that the 1 overdoser can benefit seems lacking given the severity of the outcome, the cost of the post-exposure treatment, and the lack of side effects of the pre-treatment.
posted by meehawl at 6:57 PM on June 30, 2009 [3 favorites]

If necessary, acetaminophen can be combined with an NSAID like ibuprofen as the mechanism of action is different and the analgesic effects somewhat additive.

Can anyone describe this in more detail, or describe what the effect is called so I can read up on it? I could've sworn a doctor told me exactly this years ago and I just never remembered it clearly enough to follow up.
posted by rkent at 7:05 PM on June 30, 2009

ok, which asshole at Big Pharma forgot to pay out the bribes this month?

I just checked my in-box and it wasn't me!

Phew!
posted by Kid Charlemagne at 7:06 PM on June 30, 2009 [1 favorite]

If necessary, acetaminophen can be combined with an NSAID like ibuprofen as the mechanism of action is different and the analgesic effects somewhat additive.

This would useless to those of us that cannot take ibuprofen thanks to GI problems :(
posted by Librarygeek at 7:23 PM on June 30, 2009

Librarygeek;

Worse, taking ibuprofen on a regular basis would likely lead to such GI problems.
posted by Clay201 at 7:48 PM on June 30, 2009

There does appear to be a hydrocodone (Vicodin) which is schedule III and an oxycodone (percocet) with ibruprofen instead, which is schedule II, which would be existing options but schedule II's are more of a pain in the butt.

NSAIDS are not the answer to this problem. People with kidney issues should not take NSAIDS, as they cause kidney damage. Ibuprofen, in long term use, can cause kidney cancer.

NSAIDs cause cardiac issues and stomach damage. They are not to be used by people with Chrone's Disease or IBD. They are as harmful as acetaminophen.

If the government of the USA would quit prosecuting doctors for prescribing pain medications for chronic pain sufferers, they could take the acetaminophen out of the drugs and prescribe opioids in proper doses, and protect their patient from, liver, kidney, and cardiac damage.



Sidenote: Acetylcysteine is being used to help protect kidney function in people having CT scans and taking iodine contrasts. I had to take it with several scans. It was in the form of Mucomyst which had to be drunk. It smelled of rotten eggs, and tasted even worse. And, they haven't actually found that it does any good.
posted by SuzySmith at 7:48 PM on June 30, 2009 [1 favorite]

N-acetylcysteine is used to treat acetaminophen overdoses-- I believe it's the treatment of choice for this. There was some talk in the UK of putting it in with the acetaminophen itself, thereby averting the possibility of overdose, but I think there was not enough data to support this and there are possible serious side effects so it didn't seem right to inflict it on people who were never going to come close to ODing.

It wouldn't make sense for the FDA to ban all of the schedule III's or force people who cannot tolerate NSAID's to have to take a schedule II if they have dental treatment that needs more than codeine. But sometimes they don't make sense and there is serious anti-opioid fervor around at the moment that could get translated into this and spell trouble for pain patients.

I'm consistently surprised at how willing we are to sacrifice pain patients in the name of fighting addiction, when, in fact, the efforts to do so don't actually reduce addiction but do demonstrably increase the difficulty for pain patients.
posted by Maias at 8:01 PM on June 30, 2009

I take in the area of 5-7 10mg/325mg hydrocodone/apap tablets a week. I'm prescribed 30mg a day, but I'm afraid that if I take it as prescribed, that my doctor will feel pressure to not prescribe them, or that it'll get reported somewhere. It's insane how many doctors are being prosecuted for prescribing pain meds...when most of the cases don't seem egregious to me.

In other words, despite having valid reasons (crash that had me in traction for 6 months, two knee replacements, spinal issues that cannot be repaired easily, and if that weren't enough...arthritis and neurological damage), for taking pain meds...because they help me walk, function, chase my 6 year old, do normal tasks, I don't take them as often as I probably should, because I'm afraid some three initial government agency is likely to step in and make sure I can't take them at all.

There are almost no pain specialists left because of fear of prosecution. When one of our neighbors had cancer, she had to travel all the way to Houston...a six hour car ride...to get treated and get a prescription. She passed away with half the bottle of morphine left, because she was afraid that if she took it as prescribed, they would make her go all the way to Houston again. I mean, I live in one of the largest cities in the world, and this woman couldn't get treated. Drug policies in this country are absurd.

Sure...pot would help, if it were legal. Or if I weren't a 40 year old woman surrounded by Baptists and Schoolmarms, living in an area where I don't know anyone who sparks any more.

The government lives in such freaking fear that people might take something recreationally, that they deny people who *need* the drugs, and make legitimate users feel like we're doing something wrong by asking for our pain to be treated. So, news like this is alarming. Even the possibility that these drugs will disappear, with no valid replacement on the horizon is terrifying.
posted by dejah420 at 8:14 PM on June 30, 2009 [5 favorites]

Interesting. When I worked in sleep medicine, Benedryl was considered to be the one drug we could offer as a sleep aid...
posted by Samizdata at 8:15 PM on June 30, 2009 [1 favorite]

In brighter news, look up the "drop test" for a laugh. OK, maybe that is a dark laugh.

My brother in law is an EMT and I just heard about this the other week -- in the context of a story about someone who was faking death. Apparently family drama had gotten a little out of hand and mom wanted to play the ultimate 'You'll be sorry' card.

The EMTs were unamused, to say the least.
posted by verb at 8:30 PM on June 30, 2009

gufansenin which may not even do anything...

Really? That surprises me, because it always turns unpleasant, thick mucous into nice, runny mucous for me

It doesn't seem to do much either way for me but I've seen references that question its efficacy. But obviously they keep selling it and people do swear by it. Also, I am a horrible speller as it's guaifenesin.
posted by GuyZero at 8:37 PM on June 30, 2009

We're still not giving you "medical" marajuana, hippy.

*pout*
posted by hippybear

Listen, stoned bears are worse than stoned people. Why? THE CLAWS. Sure, you think the stoned bear will be giving his new best mate a high-five, but he just tore off your arm. And then there's so much blood. So, so much blood. You're slipping around, and the bear is making growling noises of confusion. At some subconcious level, you both connect and realize it's too late. You're going to die, here in the bear cage, at the zoo, at midnight, and the bear will feast on your corpse.

Let this be a lesson, kids. Getting stoned may be fun, and getting the bear at the zoo or in the circus stoned may seem like a great idea, but it is not. Smoking the marajuana (with bears) is deadly.
posted by filthy light thief at 9:39 PM on June 30, 2009 [1 favorite]

"What a great way to punish people who have been correctly prescribed much-needed pain meds, while not preventing desperate addicts from abusing these drugs anyhow."

Geez I'm not saying make the drug useless. It should have been obvious that the chosen adulterant should behave like acetaminophen in that recommended doses have little effect and only when abused does the nasty effect of the substance kick in. And that acetaminophen should only be replaced if it is indeed only being added to opiates to make them harder to use recreationally. Because as it stands acetaminophen seems like a pretty piss-poor choice in adulterants. Surely something else that is a more obvious indicator that you are entering dangerous overdose territory could be used rather than acetaminophen whose signalling effect is a diagnosis of liver damage three days later. The puking was just an example indicator and one that starts treating an oral overdose if it happens quick enough. There must be something out there with a non linear response that won't fry an organ when the slope changes.

And anyone who needs the opiate + acetaminophen could just take two pills. Heck that would even allow one to easily change the ratio of the two drugs. Or you could make a three drug combo pill available that besides the opiate and acetaminophen included the more immediate indicator thereby reducing opiate ODs and liver damage.

But hey, as usual, it seems like the American health system is fucked up to the point where the only people it's serving is insurance and pharmaceutical companies so that's unlikely to happen. If a person in a major centre needs to travel six hours to another major centre to get a script for morphine; an acetaminophen overdose is probably low on the list of their worries. I think they prescribe vicoden in Canada but I have no idea how common that script is vs. pure opiates.

Crap the US health care/justice system makes me want to scream. I'm tempted to go out and buy 500 Pseudoephedrine tablets at the supermarket down the street just because I can. Now if only we could buy Naproxen OTC.
posted by Mitheral at 9:42 PM on June 30, 2009

"alcohol addiction isn't in the same league as narcotic addiction"

Of course it is. Not sure what that even means, but alcoholism kills a lot more people than narcotic addiction. A person can be a very functional opioid addict with known doses, and if it's clean there is almost no physiological damage. A alcoholic can also be functional, but not nearly as easy for sustained periods, and it usually will do significant damage over time.
posted by krinklyfig at 9:56 PM on June 30, 2009

I think the current stupidity regarding pain medications has a lot more to do with politics and the war on drugs than pharmaceutical and insurance companies. I mean, we're talking about dirt cheap, hundred year old drugs, not some patented cash cow.
posted by ryanrs at 10:05 PM on June 30, 2009

Since the poppy article in the April 1997 issue of Harper's, I have had the attitude that the pharmas can take their vicodin and percocet and shove 'em.
posted by telstar at 10:51 PM on June 30, 2009

According to the New York Times The FDA panel's new recommendation is to limit the max daily dose of acetaminophen (Tylenol) to 4000 mg.

Just a few months ago, my doctor wrote me a prescription for a bottle of Vicodin 5/500, 1-2 pills as needed as often as every four hours. That's a maximum dose of 2 x 6 x 500mg = 6000 mg of acetaminophen in one day.

Glad I never needed that much. Neither the doctor nor the pharmacist ever said "hey, this is a boatload of Tylenol, maybe we shouldn't do Vicodin 5/500."
posted by zippy at 11:43 PM on June 30, 2009

Can we still take it to school in our underwear?
posted by tastydonuts at 12:36 AM on July 1, 2009

cmgonzalez:

Honestly if the root cause of this set of measures is because people were too stupid to not read the labels that are on any medication they take, and thus fail to notice that they are taking excess acetaminophen, then it's overkill.

Are you kidding? People are defending this measure on the basis of people who deliberately take an entire bottle, violating all dosing guidelines, in a suicide attempt, and then are nonplussed to find out it actually worked.

Acetaminophen is a wretched substance in many ways and the risks coupled with how it's taken like candy frighten me. People should avoid taking it. But it's not a government role to ban any substance. Risk assessment on my own behalf is a job for me, my doctor, and my pharmacist.
posted by vsync at 1:06 AM on July 1, 2009

Don't you folk have integrated prescription services? Or at the least, doesn't your local drug store chain do it?

I buy my prescriptions at the local Shoppers Drug Mart. They're convenient. And they've a networked prescription record service that I'm pretty sure does a bunch of automatic checks to ensure that whatever I'm purchasing isn't contraindicated. I suspect the prescription bit of it is part of a shared province-wide databse for all pharmacies. Which only makes sense.

OTC drugs probably aren't being tracked, but it'd be easy enough to do so. Off-the-shelf drugs aren't, either; perhaps acetominophen should be moved to OTC, although it's so often for the entire family that it might be relatively pointless to do so.
posted by five fresh fish at 2:08 AM on July 1, 2009

And I refuse to buy the crappy new decongestant on the principle that it doesn't work.

FUCKING-A-RIGHT.

I can walk into a store and purchase cigarettes, alcohol, razor blades, knives, spray paint and super glue, and get hassled less than if I were to buying one lousy goddamned package of Sudafed with Pseudoephedrine. It's a fucking joke.
posted by Civil_Disobedient at 4:57 AM on July 1, 2009 [6 favorites]

I've been thinking pharmacy thoughts all night long for a lot of nights in a row, and I am tired of thinking pharmacy thoughts, but briefly

- in general I do not like combination products, and I HATE over-the-counter combination products. They are confusing. There are too many of them with too similar names. It is far too easy for patients to take the same ingredient or similar ingredients in multiple products at the same time.

- apologies if I missed this information upthread, but the opiate ingredient in Percocet is oxycodone, which is already available in an immediate release form (in other words, plain old oxycodone, not Oxycontin which is extended release) and not any more restricted than Percocet itself. I am curious to see what happens with hydrocodone.

- yeah if you're getting Lortab or something there should be at least be a brightly colored sticker on the bottle saying not to take any other APAP containing products, and if they write a sig that would allow a max of more than 4g/24 hours they should be telling you not to actually take that many

If this happens I will be doing the I Don't Work Outpatient Anymore Dance. My god it will be an epic helltorture clusterfuck to explain to every patient and every physician and get everybody switched and you know some of them have been on the same meds for years and their pain is well controlled and they don't want to change drugs and who can blame them, and new scripts and so much confusion and so many phone calls and long wait times and oh it hurts to even consider. Like the first month of Medicare Part D squared. Were I not a godless heathen I would pray for my colleagues. I'm so relieved I won't have to deal with this in that setting that I cannot contain my happiness and I have to go do the I Don't Work Outpatient Anymore Dance right now in my living room in my underwear and stripey socks brb!!!
posted by little e at 6:57 AM on July 1, 2009 [2 favorites]

okay I'm back

sorry, APAP = n-acetyl-p-aminophenol = acetaminophen and sig = signatura = the instructions on a prescription

I am way too sleep deprived and caffeinated to communicate with normal human beings right now
posted by little e at 7:01 AM on July 1, 2009

It doesn't seem to do much either way for me but I've seen references that question its efficacy. But obviously they keep selling it and people do swear by it.

You have to drink a lot of water with it. A lot. More than you want to. (When I don't, it does jack. When i drink the water, it's like a miracle.)
posted by desuetude at 8:25 AM on July 1, 2009

Here's the problem. When I was first diagnosed with fibro, I did some research and asked my doctor for Ultram (Tramadol) because it had a good track record for pain management. He gave me Ultracet (Tramadol + Acetominophen) instead, saying the Acet made it work faster.

Over time one of the other facets of my treatment stopped working as well, and instead of Lunesta for sleep, he decided to switch me to Amitriptyline instead. Because of how it works, combining with big dog painkillers like Tramadol is not recommended. So what did my doctor suggest I do when the pain flares up and I'm stuck hurting? Acetominophen. According to him I should take a couple of Tylenol as needed. No warning about daily dosage alert, no information about liver damage.

But by god, just watch his face when I try to get my Tramadol back.
posted by teleri025 at 8:40 AM on July 1, 2009 [1 favorite]

You have to drink a lot of water with it. A lot. More than you want to. (When I don't, it does jack. When i drink the water, it's like a miracle.)

Drinking a lot of water will thin out phlegm all by itself. This may well work without the guafenisin.
posted by Justinian at 10:21 AM on July 1, 2009

I can walk into a store and purchase cigarettes, alcohol, razor blades, knives, spray paint and super glue
posted by Civil_Disobedient at 7:57 AM

We should hang out.
posted by orme at 11:08 AM on July 1, 2009 [1 favorite]

Yeah, they put this crap into Vicodin/Percocet/etc precisely because it's toxic in large doses, so these drugs can be scheduled/classified more liberally than pure oxycodone/codeine/etc. I think this is an established fact and my mommy the pharamacist concurs.

The reasoning being that people are smart and will simply not abuse the drugs knowing how toxic acetaminophen is...! Doctors have sheepishly explained to me that acetaminophen by its own is weak, and the opiates potentiate it and make it more effective (ha). Don't get me started on Darvocet, which they gave to my wife after her labor, which is weaker than Vicodin but contains 650mg of acetaminophen and 100mg of propoxyphene, which is really more toxic than Vicodin if anything because it takes 20X the amount by weight to come close to the effect, but at least your baby won't get a mild buzz and get HOOKED!

And then they put a warning on the Vicodin/Percocet bottle -- "do not take with alcohol!" Done! Now they can rest assured that people won’t OD or consume alcohol – but wait! Many people are ignorant of the danger and don’t really know all that much about Tylenol (which has been disgustingly marketing itself as somehow “better” than the generic forms of acetaminophen in a time where people need to pull their heads out of their brand-name-worshipping asses).

Furthermore, the alcohol warning comes off as "this’ll be too much fun if you drink! Don’t do it!" People assume it's warning them not to have a party with the combination of opiates and alcohol, which can cause respiratory arrest but the risk is minimal with moderate consumption. But when you combine alcohol and acetaminophen, your liver takes much longer to process them both, and its toxic exposure is highly increased as a result. I thought 4 grams was the official limit for many years, not a new thing. And that's way too much...maybe 4 grams for a week to recover from a sprain or injury, but knock this shit out. The 325mg of acetaminophen in the 325/10 Percocets I got for my wisdom teeth extraction didn't do me any favors. Stands to reason that for a 5mg oxycodone Perocet, they should use 175mg of toxic crap, but I don't think 175/5 exists.

I know a few people who extol the virtues of mixing Vicodin and alcohol. It’s a sad, sad joke. Maybe you can get away with 3 drinks of less and maybe you should be seeking out the strongest combination to minimize but damage to your liver, but really -- taking Tylenol recreationally? Obviously they aren't seeking out that shit, but it comes with the territory.

Then you've got your cough medicines, most of which contain acetaminophen. No thanks, I'll buy the pure Dextromethorphan (and have my ID checked) and the pure pseudoephedrine which doesn't make my heart explode like the Preparation H they use as a decongestant now (and then register in the anti-meth registry) and maybe some guaifenesin, and mix and match myself. They'll tell you not to do this because you might actually create the exact same formula, except cheaper and without the liver damage (and the added option of hot toddies).

True pain really sucks for me, having the ol' redhead pain-tolerance genes in conjunction with a severe Aspirin allergy. No doctor will recommend that I try Ibuprofen or other NSAIDS. If I eventually feel the need, I’ll have to do it near an ER…

Potential work-spies note -- this post was composed at 6:00AM and I had trouble previewing it then, posting it now at lunch ;)
posted by aydeejones at 11:57 AM on July 1, 2009 [2 favorites]

I always thought that adding the acetaminophen to the opiate was done so that the drug would get a less strict classification. In the NDA, the drug companies show the FDA that adding the acetaminophen as not only a pain reliever but also as a semi-toxic adulterant will prevent abuse, especially by creating a solution of the opiate and injecting it.

The problem is that the smart addicts know how to separate the acetaminophen out so that they can do just that without making themselves sick. The ignorant ones don't even know that the acetaminophen is there or what the hazards of it are.

Disclaimer: I work for Big Pharma. I'm a nobody there and all of this is my personal conjecture.
posted by double block and bleed at 12:21 PM on July 1, 2009

On non-preview...
posted by double block and bleed at 12:21 PM on July 1, 2009

Elevated liver enzymes!
posted by doctorschlock at 12:49 PM on July 1, 2009

there's nothing else in Robitussin afaik, other than sugar, colour, and filler.
posted by five fresh fish at 6:41 PM on June 30

Actually, IIRC Robitussin also contains Dextromethorphan, which is a cough suppressant.

Coincidentally, it's also used recreationally. The term robo-tripping comes from people drinking stupid amounts of Robitussin to get the mild hallucinogenic effects of the DXM.
posted by arcolz at 1:17 PM on July 1, 2009

1st there are hydrocodone + acetaminophen combinations other than Vicodin. The Norco I take is 350mg APAP + 10mg good stuff vs. 500/5.

I can't believe (fictional) Dr. House could be hallucinating from Vicodin without liver damage. I suppose for the audience he's taking something people have heard of, but no Dr. would administer himself that much acetamin...

2nd:

Or, it could also be that doctors, fearing just that, will be wary of prescribing adequate pain medication.

and

Oxycontin. Doctors would rather cut off their mothers' hands and sell them on E-Bay than prescribe this stuff.

Yep. This sucks. I have fairly mild RSI with no signs (no swelling, no loss of function), just pain symptoms. When it was bad and before I learned to manage it, opiates were relief. A day or two floating off without pain would get me back to believing in a future.

Without x-rays showing shattered bone or seared and flayed skin, I'm afraid it'll be hard to get pain meds just on my say so that I have pain.

Re: oxycontin-- it's not abuse-worthy unless you crush it up. In fact if you don't subvert the time-release property this way, it's a better way to manage unrelenting pain than spikes of meds that you forget to take.

Maybe we need iPod-class (cheap & plentiful) PCA machines. A little lockbox that lets you get small dose pills every couple of hours (and chimes to remind you) that has connectivity w/ encryption to tattle to the Dr. if you crack it open or hack it.
posted by morganw at 6:59 PM on July 1, 2009

Someone mentioned Tylenol PM...yeah -- what a joke. I know many people who take it simply as a sleep aid, regardless of whether they are experiencing any pain. I tell them to buy a bottle of generic Benadryl and somehow they're taken aback.

And then there are the Nyquil junkies...my wife loves the stuff when she's got a cold, but it's really the doxylamine succinate that gives you the desired effect (zonk!). Unless you've got a fever or pain the acetaminophen is doing you no favors.

Doxylamine is just another drowsy-inducing antihistamine like Benadryl, but while many folks are somehow able to function on Benadryl in the middle of the day, doxylamine is largely out of the question unless sleep is your ultimate goal.

The brand name is Unisom but the generic is often $0.99 for a multi-week supply. I had a major cold recently and was really using the hell out of the OTC remedies (individual components as previously mentioned). Typically I tough it out and I have reason to suspect that I might be better off doing that, rather than slowing down my entire body (and perhaps immune system) with dissociatives (DXM) and anticholinergics (doxylamine).

I never noticed before, but I was getting a significant buzz off of the recommended dose of DXM before combining it with anything else.
posted by aydeejones at 6:51 AM on July 2, 2009