Tylenol can Kill

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My worst night as a doctor was during my residency.  I was working the pediatric ICU and admitted a young teenager who had tried to kill herself.  Well, she didn\’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.

On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning.  We did everything we could to keep her alive, but without a liver there is no chance of survival.

Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests.  I told the ER doctor to check an acetaminophen level and, sadly, it was elevated.  She too had taken a handful of acetaminophen at an earlier time.  She too was lucid and scared at the start of the evening.  The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant.  I got the call later that next day with the bad news: she died.

The saddest thing about both of these kids is that they both thought they were safe.  The handful of pills was a gesture, not meant to harm themselves.  They were like most people; they didn\’t know that this medication that is ubiquitous and reportedly safe can be so deadly.  But when they finally learned this, it was too late.  They are both dead.  Suicides?  Technically, but not in reality.

For these children the problem was that symptoms of toxicity may not show up until it is too late.  People often get nausea and vomiting with acute overdose, but if the treatment isn\’t initiated within 8-10 hours, the risk of going to liver failure is high.  Once enough time passes, it is rare that the person can be cured without liver transplant.

Acetaminophen overdose is the #1 cause of liver failure in the US.  According to a Reuters article, there are 1600 cases of liver failure per year (2007), 450 from acetaminophen overdose.  This is a large number.  In comparison consider that the cholesterol drug Cerivastatin (Baycol) was withdrawn from the market when there were 31 deaths from rhabdomyalysis (severe muscle break-down, which is far more common than liver failure in these drugs).  These happened mainly when the drug was used in combination with another cholesterol drug.

Should the drug be pulled from the market?  No, it is safe when used properly.  The toxic dose is generally 10 times the therapeutic dose.  My complaint is not that they have dangerous drugs available; ALL drugs should be considered dangerous.  Aspirin, decongestants, anti-inflammatories, and even antacids can be toxic if taken in high dose.  The problems with acetaminophen stem from several factors:

  1. Most people don\’t realize the danger.
  2. There has been very little public education and no significant warning labels on the packages.
  3. The drug is often hidden in combination with other drugs, including prescription narcotics and over-the-counter cold medications.  This means that a person can take excess medication without knowing it.

I would advocate putting warning labels on medications containing this drug.  I am sure this doesn\’t thrill the drug manufacturers, but the goal is not to make them happy.  I have thought this since that terrible night during residency.  If there was such a warning, perhaps she wouldn\’t have died.

It seems a bit silly that this action by the FDA is coming after their pulling of children\’s cough/cold medications.  Those drugs have very small numbers of true harmful overdoses.  The reason they were pulled was probably more that they didn\’t do anything over the fact that they were dangerous.  Acetaminophen, on the other hand, can be deadly.

Just ask the parents of my two patients.

114 thoughts on “Tylenol can Kill”

  1. Hi Dr. Rob,
    Great post, and poignant stories. I myself have seen a few cases with liver injury but no progression to failure, no deaths. And 1600 liver failures a year is a lot, to be sure, but you’ve got to put it in context of 124 million prescriptions and untold numbers of OTC tylenol purchases. I’m all for more education, more warnings, but a ban of the top combination prescription painkiller in the US seems out of proportion to the problem.

    We’ll see how this plays out — the FDA (not DEA) advisory panel was nearly unanimous on a black box warning and decreased dosages, but nearly split on banning percocet and vicodin. The FDA will take the panel’s recommendations into account before making a binding rule.

  2. Hi Dr. Rob,
    Great post, and poignant stories. I myself have seen a few cases with liver injury but no progression to failure, no deaths. And 1600 liver failures a year is a lot, to be sure, but you’ve got to put it in context of 124 million prescriptions and untold numbers of OTC tylenol purchases. I’m all for more education, more warnings, but a ban of the top combination prescription painkiller in the US seems out of proportion to the problem.

    We’ll see how this plays out — the FDA (not DEA) advisory panel was nearly unanimous on a black box warning and decreased dosages, but nearly split on banning percocet and vicodin. The FDA will take the panel’s recommendations into account before making a binding rule.

  3. My point is simply the ignorance of the danger, not how dangerous the drug is when used right. Why there were never warning labels is beyond my comprehension (although the cynic in me thinks it was McNeil pharma that prevented it).

  4. My point is simply the ignorance of the danger, not how dangerous the drug is when used right. Why there were never warning labels is beyond my comprehension (although the cynic in me thinks it was McNeil pharma that prevented it).

  5. My 85 year old mother just tossed all of her Tylenol because of this. Now we get to go see if her primary doc is willing to tell her that some amount is okay.

  6. I couldn’t agree more about labeling and education. Preventing most accidental ODs seems such a high-yield/little-effort endeavor. IMO, the drug’s safety is what allowed it to creep into so many products; ironically, this has obviously has backfired w/tragic consequences in too many cases.
    Having said that, we are talking about a VERY safe drug with a very large therapeutic window, dosage-wise, under normal conditions. Whatever gets decided in the end hopefully doesn’t forget this basic fact. Anything other than education/warnings, and perhaps options for acetaminophen-free formulations of OTC products just seems reactionary to me at this point.

  7. I couldn’t agree more about labeling and education. Preventing most accidental ODs seems such a high-yield/little-effort endeavor. IMO, the drug’s safety is what allowed it to creep into so many products; ironically, this has obviously has backfired w/tragic consequences in too many cases.
    Having said that, we are talking about a VERY safe drug with a very large therapeutic window, dosage-wise, under normal conditions. Whatever gets decided in the end hopefully doesn’t forget this basic fact. Anything other than education/warnings, and perhaps options for acetaminophen-free formulations of OTC products just seems reactionary to me at this point.

  8. My 85 year old mother just tossed all of her Tylenol because of this. Now we get to go see if her primary doc is willing to tell her that some amount is okay.

  9. Perhaps I should do a follow-up post called “Tylenol is Safe.” I probably will.

  10. Perhaps I should do a follow-up post called “Tylenol is Safe.” I probably will.

  11. Enlightened patient, thanks to good docs … was warned in ’92 about acetaminophen (which I was adding to vicodin for less narcotic, thinking it was safe!). Since then have warned numerous docs who really did not know abut hepatotoxicity of tylenol, et al.
    Again, educated a very bright PCP to availability of lower APAP formula (available as generic Lortabl) 5/350 or 7/500. Hate taking the stuff, and afraid enough of it to make it last. How do we educate both patients and physicians that “less is more”?

    Were old line straight non-combo narcotics in small doses less effective? I’m afraid that hysteria over addiction is partly responsible. 1) An addict WILL find a fix somewhere somehow; 2) A person truly in pain will seek relief.

    How can healthcare/patient advocates help be part of the answer?

    May I suggest to fine physicians: Chat with patients and tell them there is some risk of dependence on the narcotic, and a huge risk of liver failure from the acetaminophen each time you write that prescription. I really believe the average person thinks of the combo drugs as pretty harmless. Inform us, worry us, most of us will comply.

    I still see the doc who warned me in ’92, and on every visit I thank him for my reasonably healthy liver.

  12. Enlightened patient, thanks to good docs … was warned in ’92 about acetaminophen (which I was adding to vicodin for less narcotic, thinking it was safe!). Since then have warned numerous docs who really did not know abut hepatotoxicity of tylenol, et al.
    Again, educated a very bright PCP to availability of lower APAP formula (available as generic Lortabl) 5/350 or 7/500. Hate taking the stuff, and afraid enough of it to make it last. How do we educate both patients and physicians that “less is more”?

    Were old line straight non-combo narcotics in small doses less effective? I’m afraid that hysteria over addiction is partly responsible. 1) An addict WILL find a fix somewhere somehow; 2) A person truly in pain will seek relief.

    How can healthcare/patient advocates help be part of the answer?

    May I suggest to fine physicians: Chat with patients and tell them there is some risk of dependence on the narcotic, and a huge risk of liver failure from the acetaminophen each time you write that prescription. I really believe the average person thinks of the combo drugs as pretty harmless. Inform us, worry us, most of us will comply.

    I still see the doc who warned me in ’92, and on every visit I thank him for my reasonably healthy liver.

  13. I remember seeing the same thing, when a young girl was brought into the ED. She was only 13 yrs. old. They don’t truly mean to kill themselves, but are reaching out for help. I’ll never forget her. Dangerous when the public is unaware of its hazards.

  14. I remember seeing the same thing, when a young girl was brought into the ED. She was only 13 yrs. old. They don’t truly mean to kill themselves, but are reaching out for help. I’ll never forget her. Dangerous when the public is unaware of its hazards.

  15. Isn’t the effect on the liver magnified if the person is at the same time ingesting alcohol? I seem to remember hearing that.

  16. Isn’t the effect on the liver magnified if the person is at the same time ingesting alcohol? I seem to remember hearing that.

  17. I’ve always been of the understanding that the whole reason they put acetaminophen into things like Vicodin or Percocet was to reduce the risk of abuse by adding something too dangerous to allow doubling or tripling the dose by thrill-seeking users. If that’s so, seems silly to be backtracking now (although I have to say that as someone who likes her liver, I’ve always found the combination pills very annoying, because if I have pain significant enough to make me reach for an opioid, I have pain that has already broken through acetaminophen, and I do NOT WANT more acetaminophen crammed down my throat with my opioid, thankyouverymuch! )

  18. I’ve always been of the understanding that the whole reason they put acetaminophen into things like Vicodin or Percocet was to reduce the risk of abuse by adding something too dangerous to allow doubling or tripling the dose by thrill-seeking users. If that’s so, seems silly to be backtracking now (although I have to say that as someone who likes her liver, I’ve always found the combination pills very annoying, because if I have pain significant enough to make me reach for an opioid, I have pain that has already broken through acetaminophen, and I do NOT WANT more acetaminophen crammed down my throat with my opioid, thankyouverymuch! )

  19. Very good post. Made me a little teary eyed ;)I had no clue about the danger of acetaminophen.
    Do you think something (Tylenol in this case) becomes MORE dangerous when people are AWARE of its hazards? Maybe that it would be an invitation to those who are suicidal?
    (I am not saying there shouldn’t be more warning labels… but it’s a thought)

  20. Very good post. Made me a little teary eyed ;)I had no clue about the danger of acetaminophen.
    Do you think something (Tylenol in this case) becomes MORE dangerous when people are AWARE of its hazards? Maybe that it would be an invitation to those who are suicidal?
    (I am not saying there shouldn’t be more warning labels… but it’s a thought)

  21. christophil, MD

    You write-The problems with acetaminophen stem from several factors:
    1. Most people don’t realize the danger.
    2. There has been very little public education and no significant warning labels on the packages.
    3. The drug is often hidden…

    -most people I know realize the danger… well, they at least know “too much of anything can be dangerous” which should trigger a quick read of dosing instructions.
    -“significant labels”, what do you consider significant? Black Box? or BIGGER?
    – why public education? Holy Cow. My parents taught me to read labels
    – “hidden” well maybe, but not invisible… its there, you just have to look.

  22. christophil, MD

    You write-The problems with acetaminophen stem from several factors:
    1. Most people don’t realize the danger.
    2. There has been very little public education and no significant warning labels on the packages.
    3. The drug is often hidden…

    -most people I know realize the danger… well, they at least know “too much of anything can be dangerous” which should trigger a quick read of dosing instructions.
    -“significant labels”, what do you consider significant? Black Box? or BIGGER?
    – why public education? Holy Cow. My parents taught me to read labels
    – “hidden” well maybe, but not invisible… its there, you just have to look.

  23. “Dangerous” is different that lethal. I think people realize overdoses of medications can harm them, but I know for a fact that these two girls had no idea and thought the drug was safe. They both told me that. I would challenge you on whether the public realizes this is the #1 cause of liver failure. Surely you don’t suggest that the 1600/year isn’t worth addressing. Something is messed up and causing these overdoses. It’s not happening with other drugs.On prescriptions, it is often written as APAP. Do people really know this is acetaminophen? I don’t think any of my family members do. You overestimate the public.

  24. “Dangerous” is different that lethal. I think people realize overdoses of medications can harm them, but I know for a fact that these two girls had no idea and thought the drug was safe. They both told me that. I would challenge you on whether the public realizes this is the #1 cause of liver failure. Surely you don’t suggest that the 1600/year isn’t worth addressing. Something is messed up and causing these overdoses. It’s not happening with other drugs.On prescriptions, it is often written as APAP. Do people really know this is acetaminophen? I don’t think any of my family members do. You overestimate the public.

  25. I don’t think so. People who take pills are usually thought of as less serious about suicide. I am fairly certain that the majority of intentional acetaminophen OD’s are supposed to be gestures. What could be safer than Tylenol? You give it to Babies!!

  26. I don’t think so. People who take pills are usually thought of as less serious about suicide. I am fairly certain that the majority of intentional acetaminophen OD’s are supposed to be gestures. What could be safer than Tylenol? You give it to Babies!!

  27. I’m with Doc Rob.
    I’m just one of the “general public.” Until I was TOLD by an MD that “apap” was acetaminophen AND that it was NOT harmless and could injure my liver, I was oblivious. I had devoured panadol, tylenol, Excedrin Migraine, etc for years for horrible headaches, and just assumed that the gobs of vicodin being prescribed by my (then) PCP were harmless.

    I quickly got myself into interventional pain managment and highly recommend it to anyone who has such intense chronic pain that they need daily analgesia. Better to destroy a nerve than a liver.

    None of my friends until I told them again recently had any idea of the toxicity of acetaminophen and while they are the “general public” they’re not dummies. We are over-warned about medication and side effects and rare occurrences until we’re numb.

    I say put a blinking skull and crossbones on any bottle that contains acetaminophen in ANY form with a black box warning: If you like your liver, you will take less than the recommended dosage.

    And for G-d’s sake, don’t give the stuff to your kids!

  28. I’m with Doc Rob.
    I’m just one of the “general public.” Until I was TOLD by an MD that “apap” was acetaminophen AND that it was NOT harmless and could injure my liver, I was oblivious. I had devoured panadol, tylenol, Excedrin Migraine, etc for years for horrible headaches, and just assumed that the gobs of vicodin being prescribed by my (then) PCP were harmless.

    I quickly got myself into interventional pain managment and highly recommend it to anyone who has such intense chronic pain that they need daily analgesia. Better to destroy a nerve than a liver.

    None of my friends until I told them again recently had any idea of the toxicity of acetaminophen and while they are the “general public” they’re not dummies. We are over-warned about medication and side effects and rare occurrences until we’re numb.

    I say put a blinking skull and crossbones on any bottle that contains acetaminophen in ANY form with a black box warning: If you like your liver, you will take less than the recommended dosage.

    And for G-d’s sake, don’t give the stuff to your kids!

  29. Actually, it is safe for kids and I still recommend it. There is near zero chance of OD in that setting. Every drug has risk, however.

  30. Actually, it is safe for kids and I still recommend it. There is near zero chance of OD in that setting. Every drug has risk, however.

  31. Interesting. Then I stand corrected and duly informed. But how about cumulative lifetime doses beginning in childhood? What’s the line? How much is too much?

  32. Interesting. Then I stand corrected and duly informed. But how about cumulative lifetime doses beginning in childhood? What’s the line? How much is too much?

  33. The labeling changes and moving extra-strength to prescription only reflect the reality that marketing has caused people to think painkillers can be consumed like tic-tacs, to make every little ache and pain disappear. I like the quote from the doctor in this article who says Tylenol is a safe drug if used properly, but we have too many unsafe people out there. And the marketers behind these pills deserve much of the blame.http://tinyurl.com/TylenolDanger

  34. The labeling changes and moving extra-strength to prescription only reflect the reality that marketing has caused people to think painkillers can be consumed like tic-tacs, to make every little ache and pain disappear. I like the quote from the doctor in this article who says Tylenol is a safe drug if used properly, but we have too many unsafe people out there. And the marketers behind these pills deserve much of the blame.http://tinyurl.com/TylenolDanger

  35. The resources I have read say that at therapeutic doses, there really is no damage at all to the liver and hence no risk of cumulative effects. Repeatedly taking too much of the medication, however (meaning at least several times more than the recommended dose), can cause repeated injury and sometimes result in chronic liver disease. The liver is amazingly resilient overall, totally regenerating itself usually after even significant injury. It takes a lot to hurt your liver.
    Young children (under 5) are actually more resistant to having significant liver damage.

  36. The resources I have read say that at therapeutic doses, there really is no damage at all to the liver and hence no risk of cumulative effects. Repeatedly taking too much of the medication, however (meaning at least several times more than the recommended dose), can cause repeated injury and sometimes result in chronic liver disease. The liver is amazingly resilient overall, totally regenerating itself usually after even significant injury. It takes a lot to hurt your liver.
    Young children (under 5) are actually more resistant to having significant liver damage.

  37. Marketing and money, in my opinion, are a great part of the cause. It is hard to not be a cynic in this case.

  38. Marketing and money, in my opinion, are a great part of the cause. It is hard to not be a cynic in this case.

  39. That, in a nutshell is it.
    In the end, we cannot protect people from themselves. I apologize in advance for the length of my comment on a couple of aspects of human behavior, particularly that of teenage girls and women.

    Unfortunately this teenage behavior you relate is not new, and not limited to acetaminophen. Although I never knew her, I was sadly reminded of my beautiful Aunt Bessie.

    My grand mother often told me the story of Bessie’s untimely death. It was in the late 1920s. Bessie was the typical 15 year old girl, and had attended a dance against the order of my grandfather. When she heard that he had found out she thought that if she was sick, he would not be harsh with her. So, thinking it would make her sick, she swallowed carbolic acid, then in use for foot callouses. Her painful death took about 15 minutes. My grandmother was never the same, and Bessie’s death tortured her during years of senile dementia.

    Bessie thought the carbolic acid was safe, would make her sick and garner her sympathy. Whatever is in the family medicine cabinet will unfortunately be used by teenagers in this way.

    The key is indeed education, education, education. And I agree that people need to be made aware – repeatedly, continually – that the only safe “tic tac” is a Tic Tac – and then not if one is diabetic!

    A suggestion was made on NPR’s nightly news tonight (missed the name) that separating combination analgesics like Oxy- and Hydrocodone from acetaminophen would allow titration of the narcotic without increasing the APAP dosage. If you trust a patient enough to prescribe a narcotic, why not trust him/her to titrate to relief within your guidelines?

    I must say I find it more than coincidental that a hydrocodone-APAP tablet is almost identical in size and shape to a typical acetaminophen tablet. There’s consumer psychology at work there. Perhaps acetaminophen should be required to contain a safe food coloring of an alarming color, or that would give a foul odor to the urine. Few people can ignore orange or blue urine, even when they are told it’s perfectly safe. It might actually serve as a deterrent to the compulsive pill popper.

    Ya just have to trust me on that idea, fellas!

  40. That, in a nutshell is it.
    In the end, we cannot protect people from themselves. I apologize in advance for the length of my comment on a couple of aspects of human behavior, particularly that of teenage girls and women.

    Unfortunately this teenage behavior you relate is not new, and not limited to acetaminophen. Although I never knew her, I was sadly reminded of my beautiful Aunt Bessie.

    My grand mother often told me the story of Bessie’s untimely death. It was in the late 1920s. Bessie was the typical 15 year old girl, and had attended a dance against the order of my grandfather. When she heard that he had found out she thought that if she was sick, he would not be harsh with her. So, thinking it would make her sick, she swallowed carbolic acid, then in use for foot callouses. Her painful death took about 15 minutes. My grandmother was never the same, and Bessie’s death tortured her during years of senile dementia.

    Bessie thought the carbolic acid was safe, would make her sick and garner her sympathy. Whatever is in the family medicine cabinet will unfortunately be used by teenagers in this way.

    The key is indeed education, education, education. And I agree that people need to be made aware – repeatedly, continually – that the only safe “tic tac” is a Tic Tac – and then not if one is diabetic!

    A suggestion was made on NPR’s nightly news tonight (missed the name) that separating combination analgesics like Oxy- and Hydrocodone from acetaminophen would allow titration of the narcotic without increasing the APAP dosage. If you trust a patient enough to prescribe a narcotic, why not trust him/her to titrate to relief within your guidelines?

    I must say I find it more than coincidental that a hydrocodone-APAP tablet is almost identical in size and shape to a typical acetaminophen tablet. There’s consumer psychology at work there. Perhaps acetaminophen should be required to contain a safe food coloring of an alarming color, or that would give a foul odor to the urine. Few people can ignore orange or blue urine, even when they are told it’s perfectly safe. It might actually serve as a deterrent to the compulsive pill popper.

    Ya just have to trust me on that idea, fellas!

  41. christophil, MD

    Hey, don’t want to be a pest… But… you got your facts wrong. The article you cite states there are 1600 cases TOTAL acute liver failure (all cause) in US … “only” 450 cases are related to Tylenol. Of the 450 Tylenol cases approx 200 are accidental the rest are intentional. ( http://tinyurl.com/lel796 )-from data presented to FDA. Please post a correction. To put this in context, there approx 100 deaths per year in US from lightning strikes.

  42. christophil, MD

    Hey, don’t want to be a pest… But… you got your facts wrong. The article you cite states there are 1600 cases TOTAL acute liver failure (all cause) in US … “only” 450 cases are related to Tylenol. Of the 450 Tylenol cases approx 200 are accidental the rest are intentional. ( http://tinyurl.com/lel796 )-from data presented to FDA. Please post a correction. To put this in context, there approx 100 deaths per year in US from lightning strikes.

  43. I stand corrected. 450 cases per year is not insignificant, however. Both the intentional and unintentional are tragic. I will correct the inaccuracy.

  44. I stand corrected. 450 cases per year is not insignificant, however. Both the intentional and unintentional are tragic. I will correct the inaccuracy.

  45. I have run across a lot of people who tell me they are allergic to Tylenol but they can take Vicodin or Percocet. They had no idea it was in there (and many wouldn’t believe me when I told them). I think it should be changed to reflect that more clearly…. not APAP! Put “Acetamenophen” on all bottles dispensed. And then put the liver failure warnings on bottles of narcs as well as on the Tylenol bottles.

  46. I have run across a lot of people who tell me they are allergic to Tylenol but they can take Vicodin or Percocet. They had no idea it was in there (and many wouldn’t believe me when I told them). I think it should be changed to reflect that more clearly…. not APAP! Put “Acetamenophen” on all bottles dispensed. And then put the liver failure warnings on bottles of narcs as well as on the Tylenol bottles.

  47. I must respectfully disagree, Christophil. As a nurse educator, i constantly talk with well-educated people who really do not have ANY idea that tylenol = acetaminophen, and that acetaminophen is in many of the combo meds they take. (I currently live in one of the most well-educated suburbs of Chicago, and have worked all over these suburbs; but i have also practiced in rural areas in the South. )
    This is especially a problem for older people, who have difficulty reading tiny labels, and might also have a lower tolerance for the drug. They truly often are just not even aware that acetaminophen is ubiquitous. (Dr. rob, do you like that word?)

    I wrote out simply-worded, careful directions in large letters for my elderly mother, because she did not know that the daily amounts of “Tylenol PM” she was taking, PLUS her routine norco, put her right at the daily limit. And that was NOT including random times she might also take generic “tylenol” for a headache! Polypharmacy is such an issue for SO many clients.

    I certainly do not advocate eliminating this useful medicine, but i would strongly support a massive education program.

  48. I must respectfully disagree, Christophil. As a nurse educator, i constantly talk with well-educated people who really do not have ANY idea that tylenol = acetaminophen, and that acetaminophen is in many of the combo meds they take. (I currently live in one of the most well-educated suburbs of Chicago, and have worked all over these suburbs; but i have also practiced in rural areas in the South. )
    This is especially a problem for older people, who have difficulty reading tiny labels, and might also have a lower tolerance for the drug. They truly often are just not even aware that acetaminophen is ubiquitous. (Dr. rob, do you like that word?)

    I wrote out simply-worded, careful directions in large letters for my elderly mother, because she did not know that the daily amounts of “Tylenol PM” she was taking, PLUS her routine norco, put her right at the daily limit. And that was NOT including random times she might also take generic “tylenol” for a headache! Polypharmacy is such an issue for SO many clients.

    I certainly do not advocate eliminating this useful medicine, but i would strongly support a massive education program.

  49. I was never aware of the dangers of acetaminophen overdose until I began working with prevention providers for alcohol and other drugs. From my mentor I learned that you must never take acetaminophen for a hangover. Chances are you are still processing alcohol in your liver, even the next morning (ask someone who got pulled over by a cop the morning after binge drinking the night before if they can still register as over the limit that next morning–Yes). Mixing alcohol and acetaminophen is also harmful besides mixing acetaminophen with certain other drugs containing acetaminophen.

  50. I was never aware of the dangers of acetaminophen overdose until I began working with prevention providers for alcohol and other drugs. From my mentor I learned that you must never take acetaminophen for a hangover. Chances are you are still processing alcohol in your liver, even the next morning (ask someone who got pulled over by a cop the morning after binge drinking the night before if they can still register as over the limit that next morning–Yes). Mixing alcohol and acetaminophen is also harmful besides mixing acetaminophen with certain other drugs containing acetaminophen.

  51. I have on my shelf a bottle of Darvocet (Propox/Apap 100-650), to be taken as needed for arthritis pain. It says on the bottle “May cause drowsiness. Alcohol could intensify this effect. Use caution when operating a car or dangerous machinery.” It also says “Taking more of this medication than recommended may cause serious breathing problems”.
    It does NOT say “May cause liver damage. Alcohol could intensify this effect.” or “Taking more of this medication than recommended may cause serious liver damage.”

    It doesn’t even say “contains acetaminophen” unless you know that’s what APAP is, so there’s nothing to prevent taking an OTC drug containing acetaminophen even if the OTC drug has a warning on the box saying that it shouldn’t be taken with other drugs containing acetaminophen.

    I think that’s all the FDA is talking about. As someone who will probably need some sort of opiate for the rest of my life, if they’re going to be mixed with acetaminophen it would be good if the labeling reflected that clearly and a reminder that alcohol + acetaminophen = bad wouldn’t be a bad idea, either.

  52. I have on my shelf a bottle of Darvocet (Propox/Apap 100-650), to be taken as needed for arthritis pain. It says on the bottle “May cause drowsiness. Alcohol could intensify this effect. Use caution when operating a car or dangerous machinery.” It also says “Taking more of this medication than recommended may cause serious breathing problems”.
    It does NOT say “May cause liver damage. Alcohol could intensify this effect.” or “Taking more of this medication than recommended may cause serious liver damage.”

    It doesn’t even say “contains acetaminophen” unless you know that’s what APAP is, so there’s nothing to prevent taking an OTC drug containing acetaminophen even if the OTC drug has a warning on the box saying that it shouldn’t be taken with other drugs containing acetaminophen.

    I think that’s all the FDA is talking about. As someone who will probably need some sort of opiate for the rest of my life, if they’re going to be mixed with acetaminophen it would be good if the labeling reflected that clearly and a reminder that alcohol + acetaminophen = bad wouldn’t be a bad idea, either.

  53. Hi.
    I took several hundred tylenol as an over dramatic teenager, but alas, I’m still here?

    Why didn’t you save her if you saw her do it?

  54. Hi.
    I took several hundred tylenol as an over dramatic teenager, but alas, I’m still here?

    Why didn’t you save her if you saw her do it?

  55. In both cases I saw them about 12-14 hours after the ingestion. We did everything possible, but neither could be saved.

  56. In both cases I saw them about 12-14 hours after the ingestion. We did everything possible, but neither could be saved.

  57. Good news:”Taking more acetaminophen than recommended can cause serious liver problems.” CVS label on combo product in June.

    Bad news:
    July product did not have the warning.

  58. Good news:”Taking more acetaminophen than recommended can cause serious liver problems.” CVS label on combo product in June.

    Bad news:
    July product did not have the warning.

  59. Last year I attempted to take my life with about 80 tylenol (I have bipolar and was very sick at the time). Within the hour I realized what I had done, and went to the ER, assuming a stomach pump and be on my way.
    The rapid response from the staff, and the lecture every 30 minutes about liver damage really shook me. I had ZERO idea, especially since at 14 or 15, I had done something similar with a back pain drug and lived to tell the tale. After the charcoal, I was on a drip for 24 hrs to ensure my liver was ok.

    Now I won’t keep any of it in the house, in case I get sick again. I honestly never knew-so thanks for writing this.

  60. Last year I attempted to take my life with about 80 tylenol (I have bipolar and was very sick at the time). Within the hour I realized what I had done, and went to the ER, assuming a stomach pump and be on my way.
    The rapid response from the staff, and the lecture every 30 minutes about liver damage really shook me. I had ZERO idea, especially since at 14 or 15, I had done something similar with a back pain drug and lived to tell the tale. After the charcoal, I was on a drip for 24 hrs to ensure my liver was ok.

    Now I won’t keep any of it in the house, in case I get sick again. I honestly never knew-so thanks for writing this.

  61. I am very glad you got help when you did. Thanks for the comment; it probably sums the subject up better than anything I could say.

  62. I am very glad you got help when you did. Thanks for the comment; it probably sums the subject up better than anything I could say.

  63. The NYT “Well” blog had a pretty good item on acetaminophen but it left out one big piece: the connection between acetaminophen and alcohol. I wrote a comment to the Times explaining how it works: http://well.blogs.nytimes.com/2009/07/06/the-facts-about-acetaminophen/?apage=5#comment-347575
    Bottom line: regular drinkers should never take more than 2 grams of acetaminophen in 24 hours — half the recommended maximum for non-drinkers.

    My new book on health care — “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst” — talks about safe, sensible and skeptical use of medicines. I also quote from Dr. Rob in the chapter on primary care. Check out chapter one here: http://lifeyousave.com/excerpt.html

    Patrick Malone

  64. The NYT “Well” blog had a pretty good item on acetaminophen but it left out one big piece: the connection between acetaminophen and alcohol. I wrote a comment to the Times explaining how it works: http://well.blogs.nytimes.com/2009/07/06/the-facts-about-acetaminophen/?apage=5#comment-347575
    Bottom line: regular drinkers should never take more than 2 grams of acetaminophen in 24 hours — half the recommended maximum for non-drinkers.

    My new book on health care — “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst” — talks about safe, sensible and skeptical use of medicines. I also quote from Dr. Rob in the chapter on primary care. Check out chapter one here: http://lifeyousave.com/excerpt.html

    Patrick Malone

  65. Thank you! I am flattered!I agree that alcohol and chronic use are not stated well. Bottom line: safe drug but deadly in certain circumstances.

  66. Thank you! I am flattered!I agree that alcohol and chronic use are not stated well. Bottom line: safe drug but deadly in certain circumstances.

  67. One of the preventive measures here in France is to sell boxes of (8x 1000mg) Paracetamol when the toxic level is 12g.
    This way, if someone wants to take the whole box, he won’t reach that toxic level. This measure has drastically reduced the number of suicide cases.

    Still, France still doesn’t sell drugs OTC.

  68. One of the preventive measures here in France is to sell boxes of (8x 1000mg) Paracetamol when the toxic level is 12g.
    This way, if someone wants to take the whole box, he won’t reach that toxic level. This measure has drastically reduced the number of suicide cases.

    Still, France still doesn’t sell drugs OTC.

  69. I wasn’t aware that France does not sell drugs OTC. What does one do if they need an aspirin? Antacid?
    What is the cost of medical care and drugs in France?

  70. I wasn’t aware that France does not sell drugs OTC. What does one do if they need an aspirin? Antacid?
    What is the cost of medical care and drugs in France?

  71. oh i’m sorry (language problem) there is OTC but meds are sold in pharmacy only. You won’t find painkillers at the grocery store here.
    There is a precise list of drugs (paracetamol, ibuprofen, aspirin etc) that are sold without prescription but every sale is controlled by a trained pharmacist who will inquire why more than a box of paracetamol is needed.

  72. oh i’m sorry (language problem) there is OTC but meds are sold in pharmacy only. You won’t find painkillers at the grocery store here.
    There is a precise list of drugs (paracetamol, ibuprofen, aspirin etc) that are sold without prescription but every sale is controlled by a trained pharmacist who will inquire why more than a box of paracetamol is needed.

  73. Adarsh – that’s interesting. Now, here, even if we only sold NSAIDs and such “in a pharmacy” as opposed to in a grocery store or other such place, that would not mean that such sale was “controlled by a trained pharmacist.” To be controlled by a trained pharmacist, the drug must be “behind the counter,” like pseudephedrine in the USA – you don’t need a prescription, but you have to hand over ID and explain yourself for them to hand it over. Otherwise, the regular OTC stuff that’s on the pharmacy shelves – you walk in, you pay, you leave, you never see a pharmacist, no one cares. I could buy 10 huge bottles of extra-strength acetaminophen (paracetamol) at my local (mom and pop!) pharmacy, pay the teenaged checkout girl, and go on my way. But I can’t buy pseudephedrine that way. I have to present ID and have the pharmacist make sure I’m not a drug addict or manufacturer. So in France are all non-prescription drugs “behind the counter” as it were?

  74. Adarsh – that’s interesting. Now, here, even if we only sold NSAIDs and such “in a pharmacy” as opposed to in a grocery store or other such place, that would not mean that such sale was “controlled by a trained pharmacist.” To be controlled by a trained pharmacist, the drug must be “behind the counter,” like pseudephedrine in the USA – you don’t need a prescription, but you have to hand over ID and explain yourself for them to hand it over. Otherwise, the regular OTC stuff that’s on the pharmacy shelves – you walk in, you pay, you leave, you never see a pharmacist, no one cares. I could buy 10 huge bottles of extra-strength acetaminophen (paracetamol) at my local (mom and pop!) pharmacy, pay the teenaged checkout girl, and go on my way. But I can’t buy pseudephedrine that way. I have to present ID and have the pharmacist make sure I’m not a drug addict or manufacturer. So in France are all non-prescription drugs “behind the counter” as it were?

  75. Then i was right at first…there is no OTC (not yet; Sarkozy wants it though). ALL drugs are behind the counter.
    You won’t find a teenager selling drugs behind the counter. Pharmacies don’t employ salespersons…they are all degree-holders in there.

    Drugs aren’t sold in huge bottles. Non-prescription drugs are packaged to remain below the toxic level.

    Every drug I buy is kept on record. The pharmacist has access to the list of all drugs I bought during the last 60 days (i’m not sure about this figure).

    I guess these are drastic measures but it certainly helps in reducing suicide from drugs.

  76. Then i was right at first…there is no OTC (not yet; Sarkozy wants it though). ALL drugs are behind the counter.
    You won’t find a teenager selling drugs behind the counter. Pharmacies don’t employ salespersons…they are all degree-holders in there.

    Drugs aren’t sold in huge bottles. Non-prescription drugs are packaged to remain below the toxic level.

    Every drug I buy is kept on record. The pharmacist has access to the list of all drugs I bought during the last 60 days (i’m not sure about this figure).

    I guess these are drastic measures but it certainly helps in reducing suicide from drugs.

  77. Wow! I think I want to move to France. No teenagers selling OTC meds? That must also mean no GED pharm techs filling prescriptions. But I can’t translate that system into our pharmacy system where those GED undertrained techs are filling prescriptions because there is such a severe shortage of degreed pharmacists.
    What’s the happy medium here? My grandmother bought OTC paregoric for her colicky babies (didn’t seem to do any of them any harm by the way!) Would it help to follow the tobacco advertising ban and eliminate or limit direct to consumer promotion of any medicinal substance so that folks had to ask their physician or a trained pharmacist what they should buy?

  78. Wow! I think I want to move to France. No teenagers selling OTC meds? That must also mean no GED pharm techs filling prescriptions. But I can’t translate that system into our pharmacy system where those GED undertrained techs are filling prescriptions because there is such a severe shortage of degreed pharmacists.
    What’s the happy medium here? My grandmother bought OTC paregoric for her colicky babies (didn’t seem to do any of them any harm by the way!) Would it help to follow the tobacco advertising ban and eliminate or limit direct to consumer promotion of any medicinal substance so that folks had to ask their physician or a trained pharmacist what they should buy?

  79. wow that must have made some really happy babies ! Again in France, there’s no tv/radio advertising for prescription-only drugs. Still, people are aware of their existence… the pharma industry always finds its way in since the French people are among the greatest drug consumers despite the advertisement ban on prescription drugs (+alcohol, +tobacco)
    I come from the island of Mauritius… After high school, kids help to deliver drugs and sometimes the pharmacist isn’t there to supervise operations!

  80. wow that must have made some really happy babies ! Again in France, there’s no tv/radio advertising for prescription-only drugs. Still, people are aware of their existence… the pharma industry always finds its way in since the French people are among the greatest drug consumers despite the advertisement ban on prescription drugs (+alcohol, +tobacco)
    I come from the island of Mauritius… After high school, kids help to deliver drugs and sometimes the pharmacist isn’t there to supervise operations!

  81. Curious. Should we also put warnings on pieces of ropes that say tying one end around a pipe and another end around your neck can be fatal?

    How about a blanket warning on everything in this United States that says, may cause death if not used as directed? Should that suffice?

  82. Curious. Should we also put warnings on pieces of ropes that say tying one end around a pipe and another end around your neck can be fatal?

    How about a blanket warning on everything in this United States that says, may cause death if not used as directed? Should that suffice?

  83. No. The difference is the perception that Tylenol is “safe” causing people to misuse it. I spoke to both of these girls and they did not have a clue at the danger. Pipes and ropes were not made to be used to hang people, but drugs are made to go in their mouths. Yes, personal responsibility is a part of this, but if we can dispel some ignorance, isn’t it worth it?

  84. No. The difference is the perception that Tylenol is “safe” causing people to misuse it. I spoke to both of these girls and they did not have a clue at the danger. Pipes and ropes were not made to be used to hang people, but drugs are made to go in their mouths. Yes, personal responsibility is a part of this, but if we can dispel some ignorance, isn’t it worth it?

  85. Cindy Ragland,RN

    My 30 year old daughter died Dec. 1, 2008 after taking a bottle of Tylenol on Nov.30, 2008. I believe she was depressed and thought she would’nt wake up the next morning. I think she would of thought twice if she had known all the pain and suffering she would have the next day. She didn’t tell me about what she had done until almost 48 hours after the fact. When I took her to the hospital I still believe she had realized she had made a very big mistake and wanted to live but it was to late. Please educate everyone and I would like to see it written on the bottle. OVERDOSE DOES NOT KILL FAST AND A LOT OF SUFFERING HAPPENS AS YOUR LIVER DIES AND YOUR BODY SHUTS DOWN.

  86. Cindy Ragland,RN

    My 30 year old daughter died Dec. 1, 2008 after taking a bottle of Tylenol on Nov.30, 2008. I believe she was depressed and thought she would’nt wake up the next morning. I think she would of thought twice if she had known all the pain and suffering she would have the next day. She didn’t tell me about what she had done until almost 48 hours after the fact. When I took her to the hospital I still believe she had realized she had made a very big mistake and wanted to live but it was to late. Please educate everyone and I would like to see it written on the bottle. OVERDOSE DOES NOT KILL FAST AND A LOT OF SUFFERING HAPPENS AS YOUR LIVER DIES AND YOUR BODY SHUTS DOWN.

  87. Cindy, how very heartbreaking. I am so sorry for your deep loss. thank you for sharing this sad story, as a warning for all of us.
    A question for Dr. Rob or the other docs — does having a glass of wine at supper preclude using acetaminophen at bedtime (a normal 650-1000 mg dose)?

    what is the necessary time interval between taking tylenol and then having a drink? (assuming a very reasonable 24 hr intake of the drug, and a very modest alcohol intake).

    thanks.
    kathy

  88. Cindy, how very heartbreaking. I am so sorry for your deep loss. thank you for sharing this sad story, as a warning for all of us.
    A question for Dr. Rob or the other docs — does having a glass of wine at supper preclude using acetaminophen at bedtime (a normal 650-1000 mg dose)?

    what is the necessary time interval between taking tylenol and then having a drink? (assuming a very reasonable 24 hr intake of the drug, and a very modest alcohol intake).

    thanks.
    kathy

  89. Having stood along with 2 other parents in your circumstance, my heart breaks for you. Watching the suffering the person goes through is a terrible feeling of helplessness. I am very, very sorry for your loss.

  90. Having stood along with 2 other parents in your circumstance, my heart breaks for you. Watching the suffering the person goes through is a terrible feeling of helplessness. I am very, very sorry for your loss.

  91. No, a single glass of wine is not enough to be a problem. Perhaps you should listen to my podcast on the subject!

  92. No, a single glass of wine is not enough to be a problem. Perhaps you should listen to my podcast on the subject!

  93. Well I’m not to sure how much truth there is to this. I’m wondering if most of it is just a bunch of hoopla to scare folks. The reason I say this is because when I was younger I took about 30 tylenol and nothing happened outside of a bad stomach ache and feeling really sleepy for about a day. (I’m 30 now)
    Just recently I went way beyond the max dose or 4000mg in 24 hours and took 9000mg in a 24 hour period. Again I had no ill effects. I also drink on occasion and still have had no issues. It’s been a week since my first experiment to see what would happen if I went beyond the dosage.

    Or am I just lucky?

  94. Well I’m not to sure how much truth there is to this. I’m wondering if most of it is just a bunch of hoopla to scare folks. The reason I say this is because when I was younger I took about 30 tylenol and nothing happened outside of a bad stomach ache and feeling really sleepy for about a day. (I’m 30 now)
    Just recently I went way beyond the max dose or 4000mg in 24 hours and took 9000mg in a 24 hour period. Again I had no ill effects. I also drink on occasion and still have had no issues. It’s been a week since my first experiment to see what would happen if I went beyond the dosage.

    Or am I just lucky?

  95. It is possible to run through a busy street with your eyes shut and not get hit by a car. The stories I tell are true (why would I make them up to scare people?), as are those of the other people commenting. 9000 mg is not at the toxic range either.
    Read up on it – what I say is true and you are just being “lucky.” Don’t do that to yourself.

  96. It is possible to run through a busy street with your eyes shut and not get hit by a car. The stories I tell are true (why would I make them up to scare people?), as are those of the other people commenting. 9000 mg is not at the toxic range either.
    Read up on it – what I say is true and you are just being “lucky.” Don’t do that to yourself.

  97. I hope Angel’s liver transplant won’t (a) be at taxpayer expense and (b) prevent a non-self-inflicted liver injury patient from receiving one.
    See you in the morgue, Angel, unless you get some serious help. No normal person takes such self destructive chances.

    The odds of surviving Russian Roulette narrow astronomically with each repetition. I hope you get professional intervention before catastrophe occurs. In fact, if I had any idea of your identity and location I’d have no problem calling the cops. You are currently a “danger to self.”

  98. I hope Angel’s liver transplant won’t (a) be at taxpayer expense and (b) prevent a non-self-inflicted liver injury patient from receiving one.
    See you in the morgue, Angel, unless you get some serious help. No normal person takes such self destructive chances.

    The odds of surviving Russian Roulette narrow astronomically with each repetition. I hope you get professional intervention before catastrophe occurs. In fact, if I had any idea of your identity and location I’d have no problem calling the cops. You are currently a “danger to self.”

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