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THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Health Care Series (cross-posted at ePluribusmedia.  I have been invited to contribute this installment.  I originally was going to post about high fructose corn sweetener, but between the time of the invitation and now FDA came out with a new warning about acetaminophen.

Acetaminophen is one of the most widely used pain and fever relievers in the United States.  Much of the widespread use has to do with the fact that it causes less stomach upset and GI bleeding than aspirin or ibuprofen.  It is not linked to Reye Syndrome as is aspirin, making it a good choice for children and teens with flu.  Another very large reason for widespread use is heavy marketing.

However, acetaminophen has a very dark side.  According to CDC, right at half of all cases of acute liver failure (ALF) in the United States is directly caused by acetaminophen.  I will not be as geeky in this post as I normally am in my regular Sunday evening series, Pique the Geek, where we try to delve fairly deeply into the science of various topics.  However, some scientific and historical background is necessary to understand the process of liver toxicity produced by this material.

In 1887 a drug called phenacetin was first marketed for fever and pain. It is actually made from acetaminophen and is metabolized in the body to it.  It was withdrawn from the United States market in 1983 due to concerns over carcinogenicity.  However, acetaminophen had already replaced it in a large share of the market.  The reason that phenacetin was used for so long had to do with sloppy research in the early 20th century.

Acetaminophen was first introduced in 1953 by Winthrop, but in 1955 McNeil began marketing Tylenol Children's Elixir, and the Tylenol brand is still probably the most widely recognized brand name in the United States.  Now it outsells aspirin, and I believe this is a dangerous situation.

All medications are eliminated from the body, mostly as metabolites of the parent drug.  The major site of metabolism is the great chemical factory of the body, the liver.  There are three major pathways, two of them harmless.  The first one is addition of glucuronic acid (a sugar derivative) in the liver, producing a metabolite that is nontoxic and is eliminated by the kidneys.  It is thought that, in MOST people, about 40% of the drug is eliminated that way.

A second pathway, also harmless, is addition of sulfate in the liver, forming a water soluble metabolite that is carried away by the liver.  In MOST people this accounts for around 20% to 40% of the total load.

The third pathway, accounting for about 15% of drug clearance, involves the cytochrome P450 set of liver enzymes (the ones that are increased by drinking alcohol).  A toxic intermediate called NAPQI is formed, and that is cleared by combination with the natural antioxidant glutathione and eliminated by the kidneys.  Here is where the problem arises.

NAPQI is highly reactive and combines with the lipids in liver cell membranes, killing the cells.  When combined with gluatathione, it becomes nontoxic, but glutathione is essential for liver protection from the thousands of other reactive oxidizing agents that it processes constantly.  Reduction of glutathione thus also damages the liver, since it is not available to protect the liver from other bad actors.

In most people, the recommended dose of acetaminophen does not cause any outward sign of trouble.  However, there are behaviors that increase sensitivity towards toxicity.  As mentioned before, moderate to heavy alcohol intake induces the very enzyme that is responsible for the "bad" pathway, so drinkers are naturally more susceptible.  Besides, alcohol in large doses is a liver toxin in its own right, so that is a double whammy.

Another risk factor is fasting and low protein diets.  Since glutathione is derived from protein, restriction of protein intake reduces its availability, thus decreasing its protective effect on the liver.

A third risk factor may be caffeine.  Some fairly recent work is consistent with the hypothesis that caffeine induces a liver enzyme that also causes the production NAPQI, presumably Cytochrome P450.  Now this is problematic for a couple of reasons.  First, many folks drink a lot of coffee.  Second, caffeine is often added to painkiller medications to increase their potency.  Some of these combinations include acetaminophen.

There are also other drugs that induce these enzymes, particularly anticonvulsants.  The barbiturates are potent inducers, and a few combination products contain a barbiturate, a narcotic, and acetaminophen.

In most normal people with no other risk factors, four grams of acetaminophen will show up on liver function tests after a few days for about a third of the population.  Well, four grams a day is the maximum recommended dose for Tylenol Extra Strength products according to the Tylenol website.  So, recommended doses affect liver function in one third of people with no other risk factors.  This is not good.

Six grams a day for two days can cause significant liver function disturbances in normal (that is, no other risk factor) individuals.  Now, I know a lot of folks who have the attitude, "if two tablets will help, three will help more."  Here is how we start getting into trouble.

But there is a more insidious overdose danger.  There are so many products that contain acetaminophen that it is easy to take an overdose and not even suspect it.  Many of them are over the counter, and many others are prescription drugs.  This is, in my opinion, the greatest threat for overdose.  I carefully read the labels of any OTC materials that I buy (and I do not get that many) to assure that they do not have any acetaminophen in them.  I use aspirin or ibuprofen for pain (I recently burnt my fingers severely as readers of Pique the Geek are aware) and the ibuprofen was very welcome.  I choose not to take acetaminophen in any form, and am fortunate that I tolerate aspirin and ibuprofen well.

I strongly urge everyone to be aware of ingredients in all OTC and prescription medications.  You can tell from the label for OTC materials, but for prescription medications you pretty much have to look them up online of, better, to ask the pharmacist directly whether there is any acetaminophen in your prescription, and if so, how much.  If you have a prescription that contains the maximum recommended dose and unknowingly take the maximum dose of OTC acetaminophen, you are at eight grams a day right off the bat.

Another potential danger out there is for infants and children.  Modern medical practice is not to give aspirin to children under 18 for fever (it is OK for muscle pain or headache) because of Reye Syndrome.  Thus, until ibuprofen became available OTC, acetaminophen has been the drug of choice.  A common mistake is substituting infant's acetaminophen drops for children's acetaminophen elixir.  The drops are much higher in concentration and should be given only with the little dropper that comes with them.  Using the directions for the weaker elixir with the drops will overdose your toddler, so be sure not to get the dosages mixed up.

How do you know if you have been poisoned?  After a few hours you will begin to feel bad, sometimes just "run down" in general.  Nausea and vomiting and sweating is not uncommon.  Vomiting is a good thing, if any is left unabsorbed in your stomach.  After about eight hours the damage is done and if severe enough pain on the right side of the abdomen from swelling and liver enzymes are haywire.  Kidney failure may also begin.  After a few days, you are either going to get over it or not.  No treatment is effective if given much after eight hours, except for liver transplant.  Those are sort of hard to get, especially in the quick.

There is a very effective treatment if given within the first eight hours.  There is a drug called acetylcysteine that can be given by emergency department staff.  It is metabolized to glutathione, which we talked about earlier.  This replaces the depleted glutathione, the important antioxidant, and significantly reduces liver damage.  If you wait too long, though, the liver cells are already dead and this will not revive them.  It just protects the ones still living.

I should point out the difference between acute poisoning and chronic poisoning.  In acute poisoning (very high single dose event), then the emergency department can give you activated charcoal to absorb any drug not yet out of the GI track, the acetycysteine to protect the liver, and you will likely be OK, IF you get to the emergency department fast.  On the other hand, the chronic overdosage caused by taking more than the recommended amounts of the drug add up over the months and years and can not really be treated except for avoiding the drug altogether.

Here are my recommendations for acetaminophen:

o  Eliminate the drug in any combination product, prescription or OTC.  This one step would eliminate accidental overdose caused by not knowing that you are taking it twice (or more).  If acetaminophen is needed, then plain tablets or capsules can easily be added to the other drug.  For example, if you need Percocet, the physician can prescribe oxycodone tablets and acetaminophen tablets with dosage instructions for both.  It might be a little more trouble, but I believe that this one step would reduce cases of accidental overdose significantly.

o  Eliminate adverts for acetaminophen and products containing it in the popular media.  This may have some First Amendment issues, but we did it for tobacco on the TeeVee and radio.  The big drug houses have a vested interest in selling as much as they can.  I see more adverts for acetaminophen than for any other OTC drug.

o  Make acetaminophen a "behind the counter" drug, like pseudoephedride.  This way, a pharmacy employee would be available to counsel the purchaser on the dangers of acetaminophen overuse.  This is less extreme than the third suggestion, which I prefer, but likely to be more acceptable to people.

o  Make it prescription only.  I prefer this approach.  This is the most onerous way to reduce toxicity, but in this case both a physician and a pharmacist would be involved in counseling the patient about the dangers of this drug.  I am not saying to make it a controlled substance like opiates, but prescription like antibiotics.

Finally, here are my personal opinions about acetaminophen:

o  It is a dangerous drug that is way, way overadvertised and overused.

o  I choose not to take it in any form.  I check labels on everything that I buy.

o  I strongly recommend that adults who tolerate aspirin to use aspirin.  Ibuprofen is fine, too, for those who can tolerate it and is approved for children.  It is cheap, safe, and effective.  Naproxin is also a good choice for those who can tolerate it.

o  For those who can not tolerate aspirin, ibuprofen, or naproxin, take the lowest dosage consistent with relief for the shortest amount of time.  Do not drink any alcohol while you take acetaminophen.  This actually is only a partial fix, since the liver enzymes induced by alcohol are already there and take several weeks to go back to normal levels.  Do not use caffeine, and if you take antiseizure medication, or any medication for that matter, ask your physician what to do.  The only problem with that is that physicians are heavily influenced by the drug companies and sometimes do not have the best information available, but better than nothing.

I now conclude this installment.  I want to express my appreciation to TheFatLadySings for inviting me to guest host this evening.  I will stick around for a while for questions and comments.  Please visit my science series, Pique the Geek here on Kos and crossposted at docudharma, at 9:00 PM Eastern every Sunday evening.  The next installment will be about the psychedelic amphetamines as part of the series Drugs of Abuse.

Crossposted at docudharma.

Update:  Folks, it is after midnight now.  I appreciate the opportunity to post on this astute series tonight, and hope to do so again some day soon.  Thank everyone for the good comments and questions.  Please see me Sunday as indicated just two paragraphs above here.

Warmest regards,

Doc

Originally posted to Translator on Thu Jun 11, 2009 at 05:58 PM PDT.

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Comment Preferences

  •  Tips for avoiding poisoning? (46+ / 0-)

    The Thursday Night Weekly Health Care Series is published every Thursday. It is meant to provide a forum and encouragement for people organizing for positive health care change.

    Upcoming diaries:

    June 18: suescannon- My Experience Being Arrested by the US Senate

    June 25: TheFatLadySings- Including a State Option in Health Care Reform

    If you would like to contribute to the series, please contact TheFatLadySings at tflsster/at/gmail/dot/com.

    Warmest regards,

    Doc

    "It is not the content of the post, it is the name recognition that makes the Rec List"

    by Translator on Thu Jun 11, 2009 at 05:47:09 PM PDT

    •  My BIL lost his liver due to a combination (7+ / 0-)

      Of acetaminophen, beer, and athsma medication. It was very sudden.

      He had hurt his back and took acetaminophen at the max dose for a few days. He is  farmer and happened to be a beer drinker, he also has asthma, and, especially during the summer, needed his inhaler.

      This was all before the big warnings about drinking alcohol in combination with acetaminophen.

      When he got onto the transplant list (nearly 10 years ago), he was told there were 10,000 people head of him. He is still waiting.

      He had to have a liver bypass a few years ago, because nothing could pass through it anymore. The poison levels in his body are managed with medications, but only marginally. He gets pneumonia frequently, and has recently developed diabetes. He can be physically active for an hour or two per day.

      For some reason, no one knows why, his liver has started regenerating. The doctors have told him to keep doing whatever it is he's doing. No one knows if the process will continue, or if it will remain functional should they un-do the bypass. Everyone has their fingers crossed. It would be amazing if he could end up surviving with his own liver after all this. It's been a looooong road.

      Get your DemocracyFest tickets, today! http://www.democracyfest.net

      by mataliandy on Thu Jun 11, 2009 at 07:20:15 PM PDT

      [ Parent ]

    •  yup: narrow therapeutic window (6+ / 0-)

      the difference between effective dose and poison is less than with most drugs.

      Thanks.

      •  The one that jumps to mind (2+ / 0-)
        Recommended by:
        sberel, TheFatLadySings

        is lithium.  A very, very narrow therapeutic versus toxic window.  Digoxin is another one.

        Warmest regards,

        Doc

        "It is not the content of the post, it is the name recognition that makes the Rec List"

        by Translator on Thu Jun 11, 2009 at 08:13:07 PM PDT

        [ Parent ]

        •  Yep (0+ / 0-)

          Why I got so excited when a nurse gave me two digoxin in my daily meds at the hospital once, instead of the single indicated.  Fortunately they dye those pills bright blue so it was easy for me to spot-the nurse must have been color blind or just didnt read the chart.  

          Democrats give you the Bill of Rights; Republicans sell you a bill of goods!

          by barbwires on Sun Jun 14, 2009 at 07:09:21 PM PDT

          [ Parent ]

  •  thanks for the valuable info, doc (6+ / 0-)

    I eliminated all acetaminophen from my meds a while ago, although I was never aware of the extent of the dangers of overdose on the drug until I read this diary.
    Once again, your diary is an educational experience.
    It's always nice to see you here, doc.

    -7.88/-4.41 "The blood sucking aristocracy stood aghast; terror stricken, they thought the day of retribution had come." - John Ferral, union leader

    by Interceptor7 on Thu Jun 11, 2009 at 06:14:40 PM PDT

  •  I have an acetomenophen story which I will post (12+ / 0-)

    and then I'll read your excellent diary. About 8 years ago, I conducted a study of overdose deaths in my county after the NM Secretary of Health announced we had one of the highest heroin overdose death rates in the nation. I did not find any strict heroin overdose deaths. I found a very high rate of mixed drug deaths. Alcohol was the most frequent culprit, closely followed by heroin.

    I also found a young man who died of a tylenol overdose because he had a horrible toothache. The nearest dentist was four and a half hours away. He died as his parents were driving him to the dentist.

    Tonight, I am utterly doped up on Ibuprophen and lortab because of an ear infection. I specifically did NOT request Tylenol 3 because I knew this diary was on the way!

  •  Thank you (8+ / 0-)

    Never used it much, simply because it wasn't very effective. Its a poor pain reliever and doesn't reduce inflammation.

    Same for my children, I used it as little as possible and switched to children's ibuprofen when it came out.

    We've known about the risks of using acetaminophen since it first came on the market.  I could never figure out why it was being pushed so hard by docs and hospitals.

    When we lived in Texas in the 1980's, the local newspaper (for some unknown reason) did a series about suicide - listing all the suicide related deaths in the county for the last year.  I was shocked at how many of these deaths were the result of acetaminophen poisoning.  Far more than any other drug legal or otherwise.

    Glad the public is being educated.

    Private health insurers always manage to stay one step ahead of the sheriff - Sen. Sherrod Brown

    by Betty Pinson on Thu Jun 11, 2009 at 06:19:35 PM PDT

  •  Guess I was lucky that Tylenol (4+ / 0-)

    made my headaches worse instead of better.  Aspirin remains my lifelong drug of choice.

    What FDR giveth; GWB taketh away.

    by Marie on Thu Jun 11, 2009 at 06:25:37 PM PDT

  •  It works for me (6+ / 0-)

    aspirin and ibuprofen irritate my stomach.  However, I'm generally anti-excessive medication -- about two to four tylenol type pills in a month.

    Healthy Minds & Bodies, discussing outdoor adventures Tuesdays 5 PM PDT

    by RLMiller on Thu Jun 11, 2009 at 06:27:05 PM PDT

  •  Interesting, thank you. A question about its name (5+ / 0-)

    Acetaminophen in the USA, Paracetamol in the British English-speaking world. How did the difference in naming arise?

    I know of another international difference in medication names that has the potential for confusion: a case of not two names for one product as above, but different products sharing a name.

    An in-law relative of mine visiting New Zealand from the USA needed to buy "Benadryl" but found that Benadryl in NZ is not what they needed at all ... not the same as Benadryl in the USA. This was back in the olden days, late last century before everyone used Google and Wikipedia to figure out such stuff, but we managed to sort it out with a bit of web searching.

    •  The developer of a drug (6+ / 0-)

      can give it whatever generic and brand name that it chooses, with some limits.  Acetaminophen is sort of an acronym since there is an acetyl group, a phenyl ring, and such.  Paracetamol has to do with the the two groups on the phenyl ring being para (that is, opposite to each other) and once again, an acetyl group.  The only real way to identify chemical compounds is the IUPAC names and the CAS registry numbers.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 06:37:17 PM PDT

      [ Parent ]

  •  How common a problem is this? (5+ / 0-)

    I know you're generally a calm guy, and that you aren't one to post hysterical diaries, so my assumption up front is that this is indeed a serious issue.

    But how serious?  What led the FDA act now?  And what's known about the number of incidents a year?

    We've seen a lot of issues with different anti-fever and anti-pain drugs over the last few years.  My first instinct is to ask: drug X has problems, but are they any more serious than drug Y?  And are there any cases where drug X is still a better drug than drug Y?

    No drug is absolutely safe, and even excellent drugs can cause problems.  Even aspirin has issues (Reyes Syndrome, stomach bleeding, etc.)  What are the trade-offs here.

    "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

    by mbayrob on Thu Jun 11, 2009 at 06:32:19 PM PDT

    •  My pediatrician counseled me very seriously (6+ / 0-)

      when my kids were little to avoid acetominophen if possible, and to be careful to not confuse the infant bottles with the children's bottles. They said they saw a lot of accidental overdoses in very young children.

      I was unaware of the issue before that. My kids had allergies, ear infections and colds, hence the discussion. I had no idea until I ran across that one death record (see above) that it could be dangerous to adults.

      A funny story: When my son was two, he got an ear infection. I shoved some OTC meds down his throat. This made him very angry. He arched his back and his eyes rolled into his head and he turned purple. I thought I had poisoned him so I drove at top speed to the ER where the nurses started laughing.

      One of them asked, "I guess this is your first child and you've never seen a temper tantrum before?!"

      Actually, he was my second, but my daughter's tantrums consisted of demanding to where purple and white polka dots with orange and pink plaid....

    •  Just about half of all cases of acute (3+ / 0-)
      Recommended by:
      mataliandy, mbayrob, trashablanca

      liver failure in the US are caused by acetaminophen overdose, according to the CDC.  According to a recent article in Hepatology, there were 100,000 poison control center calls, 56,000 emergency department visits, 2600 admissions, and 458 deaths per year.  This is pretty big problem, and the stats do not address how many liver transplants were done on account of it.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 06:41:49 PM PDT

      [ Parent ]

      •  That qualifies as a serious public health issue (3+ / 0-)

        At a minimum, the drug is overused in over-the-counter remedies.

        Here's a reverse version of the question:  are there any cases we use acetaminophen that we couldn't be using something else?

        You're making a really good case for drastically reducing this drug's use.  At this point, I'd want to know if there's any reason we should be using it at all.

        "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

        by mbayrob on Thu Jun 11, 2009 at 07:00:55 PM PDT

        [ Parent ]

        •  There are many legitimate uses (4+ / 0-)

          for this drug.  For instance, for some folks with clotting problems due to low platelet count, all of the NSAIDS are contraindicated, leaving only acetaminophen for mild to moderate pain relief.  But these folks should already be under the care of a qualified medical professional who should understand the risks involved.

          I do not advocate banning it outright, because it has value is some cases, but it is not a panacea for everyone.  Good question.

          Warmest regards,

          Doc

          "It is not the content of the post, it is the name recognition that makes the Rec List"

          by Translator on Thu Jun 11, 2009 at 07:05:19 PM PDT

          [ Parent ]

  •  It definitely doesn't help that it's so cheap. (4+ / 0-)

    Go to the local grocery store and you can usually get 500 extra strength acetaminophen tablets for about $2. It seems like everyone has a generic tylenol, and it's always easier to find the generic "tylenol cold and sinus" than it is to find just the "cold and sinus" part.

    Thanks for the diary. I knew acetaminophen was dangerous, but never really realized how much. Considering it takes about 4 extra strength tylenol for me to even notice I took them, I guess I should cut them out.

    •  If you can tolerate aspirin or ibuprofen (1+ / 0-)
      Recommended by:
      TheFatLadySings

      or naproxin, I strongly urge you to use them instead.

      With an aspirin OD, your ears ring and you get sick.  The next day your are fine.  With an acetaminophen one, you just might need a new liver.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 06:44:06 PM PDT

      [ Parent ]

      •  ibuprofen does seem to have advantages (4+ / 0-)

        I just went over the Wikipedia articles on the two drugs, and except for problems with people with inflammatory bowel disease, there aren't too many severe problems with ibuprofen.  It does seem generally safer.

        The key take-away, I think, is to reduce the "hidden" use of acetaminophen in cold relief remedies and such, since OD does seem to be particularly dangerous for this drug.

        "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

        by mbayrob on Thu Jun 11, 2009 at 07:17:21 PM PDT

        [ Parent ]

      •  LOL (2+ / 0-)
        Recommended by:
        Translator, TheFatLadySings

        With an aspirin OD, your ears ring and you get sick.

        Unless you're a 3 year old who looooooves the orange-y flavor of Johnson's Baby Aspirin, and you use the toilet and sink as a staircase to get into the medicine cabinet and eat the whole bottle.

        In that case, your kidneys and GI tract are at serious risk, and you find yourself in the hospital getting your stomach pumped.

        Not that I know anyone who did that as a 3 year-old (cough) me (cough).

        Get your DemocracyFest tickets, today! http://www.democracyfest.net

        by mataliandy on Thu Jun 11, 2009 at 09:09:09 PM PDT

        [ Parent ]

        •  And that there is no such of a thing (2+ / 0-)
          Recommended by:
          mataliandy, TheFatLadySings

          as "baby aspirin" any more.  They just repacked it and give it to the old folks as "heart medicine".  I kid you not.  Same stuff, just for a different audience.

          Warmest regards,

          Doc

          "It is not the content of the post, it is the name recognition that makes the Rec List"

          by Translator on Thu Jun 11, 2009 at 09:26:14 PM PDT

          [ Parent ]

          •  actually, there is (1+ / 0-)
            Recommended by:
            Translator

            my daughter had Kawasacki syndrome and the treatment for that is aspirin - it's one of the only indications for using aspirin in kids. St. Joseph still makes the orange flavored 81 mg tablets.

            Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

            by stitchmd on Fri Jun 12, 2009 at 12:20:59 AM PDT

            [ Parent ]

            •  Indeed the product is (0+ / 0-)

              still marketed, but, as I said, marketed to adults for heart health.  Subtle difference, but real.

              In the case of your child, this was given under the direction and supervision of a physician, I am almost sure.  This is quite different than going to Big Box and just picking it up off the shelf with no professional involvement.

              I wish your child well.

              Warmest regards,

              Doc

              "It is not the content of the post, it is the name recognition that makes the Rec List"

              by Translator on Fri Jun 12, 2009 at 03:40:07 PM PDT

              [ Parent ]

      •  aspirin overdose can be deadly (1+ / 0-)
        Recommended by:
        Translator

        it's not just about ear ringing. It can lead to serious metabolic effects - it affects the acid-base status both at the respiratory and metabolic pathways. It will make most people feel sick, unlike acetaminophen, but in significant doses aspirin can have serious consequences, and there is no antidote unlike mucomyst for acetaminophen.

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

        by stitchmd on Fri Jun 12, 2009 at 12:24:53 AM PDT

        [ Parent ]

        •  True enough, but I think that you are addressing (0+ / 0-)

          acute overdose rather than chronic.  Taking two, three, or even more times the recommended dose of aspirin will finally catch up with you with tinnitus and other symptoms, such as GI bleeding.  But it does not cause severe liver damage at three to four times the recommended dose as APAP does.

          Warmest regards,

          Doc

          "It is not the content of the post, it is the name recognition that makes the Rec List"

          by Translator on Fri Jun 12, 2009 at 03:42:38 PM PDT

          [ Parent ]

          •  It's not just that (1+ / 0-)
            Recommended by:
            Translator

            aspirin does far more than give you tinnitus and GI bleeding. Overdoses of aspirin can cause severe mixed acid-base disorders which can lead to coma, seizures and death.

            Yes, this is about acute poisoning, but it can accumulate over a period of time too, and it can also be related to other medications. Pepto-Bismol, for example, contains salicylates; using that along with aspirin can lead to unintended overdose.

            Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

            by stitchmd on Sat Jun 13, 2009 at 11:40:01 AM PDT

            [ Parent ]

  •  My allergies have led me (5+ / 0-)

    to the ER too many times, and I've had a lot of IVs.  I always get a distinct, separate taste from Benadryl, ranitidine, and steroids through and IV.  They don't last long, but they're definite.

    Same thing with Tylenol.  It's a strong, unpleasant taste.  Any idea why, Doc?

    "Republicans are poor losers and worse winners." - My grandmother, sometime in the early 1960s

    by escapee on Thu Jun 11, 2009 at 06:41:26 PM PDT

  •  Fuck (6+ / 0-)

    Acetaminophen work the best for me.  Certainly better than ibuprofen, which might as well be candy.  

    What about naproxum sodium?

  •  Are there certain populations that have more (3+ / 0-)
    Recommended by:
    sberel, escapee, Translator

    difficulty metabolizing acetominophen? I live in a primarily Hispanic and Native American community. There seem to be a greater vulnerability to alcohol and refined sugars in my community, if rates of cirrhosis, diabetes, etc., are an indicator.

    •  It is known that some people (1+ / 0-)
      Recommended by:
      TheFatLadySings

      metabolize drugs at different rates, and some are very sensitive to acetaminophen.  The ones that seem to clear it out faster seem to have more of the third pathway going, with concomitant liver damage.  I am not aware of any studies involving specific ethnic groups, but it is known that individuals vary.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 06:49:54 PM PDT

      [ Parent ]

      •  Maybe there SHOULD be some studies done. (2+ / 0-)
        Recommended by:
        mataliandy, Translator

        Maybe a whole bunch of OTC products for infants with acetominophen in them are not a good idea in my community. Even more so than in other communities.

        I wonder who I could ask about this?

        •  I suspect that some studies are (1+ / 0-)
          Recommended by:
          TheFatLadySings

          either ongoing or proposed.  We are just now learning about this topic.  I suspect that in a few decades, if our health care system does not implode from excessive profits for the insurance and drug companies, that genetic testing will be done for individuals, not groups, to fine tune drug dosages.  Groups are sort of like a sledge hammer approach (better than nothing, obviously) and specific genetic analyses are more like the oft referenced "silver bullet", tailored to each individual.

          Warmest regards,

          Doc

          "It is not the content of the post, it is the name recognition that makes the Rec List"

          by Translator on Thu Jun 11, 2009 at 07:08:56 PM PDT

          [ Parent ]

          •  That's true but if there is an inherited (1+ / 0-)
            Recommended by:
            Translator

            vulnerability among Native Americans and Hispanics, then I think our local docs should know about it today.

            I find that frequently, when we test drugs, we forget to look at women and ethnic minorities. It's a serious problem.

            •  I fully agree. But not everyone inherits (1+ / 0-)
              Recommended by:
              TheFatLadySings

              everything the same way.  Sure, use ethnicity as a starting point to learn who needs individual screening more.  To remove the emotion, let us use a different ethnic group.

              Just because one Asian from, say Japan, has a particular liver enzyme profile does not indicate that another individual from the same town has it as well, until studies are performed.  Ethnicity is a good start to find answers, but the final answer will be much more complex, I promise you as a scientist.

              Warmest regards,

              Doc

              "It is not the content of the post, it is the name recognition that makes the Rec List"

              by Translator on Thu Jun 11, 2009 at 07:51:52 PM PDT

              [ Parent ]

  •  The advice about combination with caffeine (3+ / 0-)

    is interesting.

    There are "extra strength" variants that have the same amount of acetaminophen as the regular kind, but also have some caffeine in each tablet, right? I avoid all caffeine, as I seem to be particularly sensitive to its effects on heart rate. Instant decaf is fine, but even weak instant non-decaf has me regretting I drank it.

    I remember reading some article about acetaminophen with caffeine once, a while ago ... ah, here, it was possibly this one: Caffeine painkiller risk claimed, BBC News, Sep 2007.

    •  Caffeine has been put into (3+ / 0-)
      Recommended by:
      retrograde, sberel, TheFatLadySings

      combination OTC, and prescription, pain relievers, for about a century now.  The reason is, well, it works.  Same advice to caffeine sensitive individuals:  read the label and ask the pharmacist.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 07:10:39 PM PDT

      [ Parent ]

  •  I have never understood why (2+ / 0-)
    Recommended by:
    Translator, TheFatLadySings

    anyone would willingly take Tylenol.  I've taken Tylenol 3 for severe pain, occasionally, just because it has codeine in it...but Tylenol simply does not work.  I've tried it, and an hour later, my pain is not in the least bit relieved.

    Ibuprophen is great; aspirin is great.  But Tylenol?  fuggeddaboudit.

    (& I read somewhere, years ago, that it doesn't work on roughly 40% of the population...of which I guess I'm one.)

    So I can't understand why doctors keep pushing it.

    GOP: Turning the U.S. into a banana republic since 1980

    by Youffraita on Thu Jun 11, 2009 at 06:51:26 PM PDT

  •  I'm not as strict about it as Doc (4+ / 0-)

    because it works for me and I'm aware of its toxicity in high doses and watch how much I take. I never take "extra strength" for example.

    But point well taken that it's ubiquitous and drug manufacturers literally make "witches brews" with the stuff. And for the love of God, don't take it with alcohol at all. (I don't drink alcohol so I don't have to worry about that one)

    And another thing they do with "Tylenol" is to intentionally use it as a poison.

    How's that?  Acetaminophen is put into prescribed pain-killers so that if you try to abuse the narcotic, you'll die of acetaminophen poison first. It makes it so the DEA feels a little bit better about your not feeling good off that hydrocodone in your Lortab. And it's the only reason hydrocodone can remain a Schedule III drug instead of, say, oxycodone (Rush's fave!) which is Schedule II and thus more closely monitored.

    This ain't no party. This ain't no disco. This ain't no foolin' around!

    by Snud on Thu Jun 11, 2009 at 06:53:44 PM PDT

    •  Really? Is that why they put it in there? (2+ / 0-)
      Recommended by:
      Snud, Translator

      But why would poisoning people who are dependent on one drug with another make the FDA feel good? I'm too buzzed on lortab and ibuprophen at the moment, to process what you just said.

      And apparently acetooaminophen as well, albeit unwittingly.

      And anti-biotics.

      •  LOL... Yeah, it actually is (5+ / 0-)

        Oxycontin, for example, is oxycodone with no acetaminophen. Because there's no "tylenol" (same thing as acetaminophen) you can, if you have the tolerance built-up, take a handful of them. Opiates aren't particularly toxic to the liver at all, so again, if you are used to them - like Rush - you can take a handful of Oxycontin.

        The DEA knows this and thus oxycodone (the active ingredient in Oxycontin) is a Schedule II drug. That means a doctor cannot prescribe it to you over the phone and you must have a written prescription for it.

        Hydrocodone is pretty similar in effect and dose to its cousin, oxycodone. (It may be a little weaker but not much) Hydrocodone is almost always mixed with tylenol - Lortab is a prime example. Lortabs are a Schedule III drug, which means a doctor - or dentist - can phone it in for you.

        This is a good thing, otherwise it'd be a huge pain in the ass for dentists, etc. to phone in some effective pain meds for you.

        But the DEA doesn't trust you. So they insist drugs like Lortab keep the tylenol so if you do try to abuse it - by taking a handful of it - you'll probably die of liver failure from the tylenol long before you OD on the hydrocodone.

        Junkies know this, and of course, have figured an easy way around it. Google "cold water extraction" and you'll see what I mean.

        This ain't no party. This ain't no disco. This ain't no foolin' around!

        by Snud on Thu Jun 11, 2009 at 07:08:12 PM PDT

        [ Parent ]

        •  Off to top comments with you! n/t (1+ / 0-)
          Recommended by:
          Snud
          •  I would advise more reflection and study (2+ / 0-)
            Recommended by:
            Snud, TheFatLadySings

            on your part before you do that.

            Warmest regards,

            Doc

            "It is not the content of the post, it is the name recognition that makes the Rec List"

            by Translator on Thu Jun 11, 2009 at 07:22:47 PM PDT

            [ Parent ]

            •  And I'd just as soon not be top commented (2+ / 0-)
              Recommended by:
              Translator, TheFatLadySings

              for that either! ;-) But I really do believe what I said is accurate, Doc, and would urge you to check on me on this.

              This ain't no party. This ain't no disco. This ain't no foolin' around!

              by Snud on Thu Jun 11, 2009 at 07:31:17 PM PDT

              [ Parent ]

              •  Too late. (2+ / 0-)
                Recommended by:
                Snud, Translator

                Reflection and study don't mix with lortabs. I can barely operate a cursor.

                I think your comment was interesting. It bugs me that after specifically requesting ibuprophen in order to avoid acetamenophen, despite the fact that I have a very good doctor, I ended up ingesting acetaminophen anyway. In ADDITION to ibuprophen.

                Your comment is food for thought...

                •  I sound like John Belushi. ;-) n/t (2+ / 0-)
                  Recommended by:
                  Translator, TheFatLadySings

                  This ain't no party. This ain't no disco. This ain't no foolin' around!

                  by Snud on Thu Jun 11, 2009 at 07:40:29 PM PDT

                  [ Parent ]

                  •  Why? Are you doing speedballs? (2+ / 0-)
                    Recommended by:
                    Snud, Translator

                    I suspect that I might be doing 'em.

                    •  No speedballs for me! (2+ / 0-)
                      Recommended by:
                      Translator, TheFatLadySings

                      I've never even seen heroin. But as I mentioned, I was on chemo and, for a while, Oxycontin - when it first came out in the late 90's, before all the poo hit the fan with it.

                      My doc had me on 60mgs a day - which for me was a lot. But I knew someone who was prescribed many, many times that. He had a tolerance though (broke his back) and could take ungodly amounts every day.

                      One reason he could safely be prescribed that much is because there's no tylenol, aspirin or caffeine in Oxycontin and again, narcotics aren't terribly hard on the liver. If you're tolerant (been taking them a long time) you can take a LOT.

                      Now... when it's time to stop, well... you got a major problem!! ;-)

                      This ain't no party. This ain't no disco. This ain't no foolin' around!

                      by Snud on Thu Jun 11, 2009 at 08:14:37 PM PDT

                      [ Parent ]

                      •  Agreed on two points. (2+ / 0-)
                        Recommended by:
                        Snud, TheFatLadySings

                        60 mg a day is a LOT!  And that you did not get your poisoned with other, unnecessary drugs.  For severe pain, hard, Schedule II narcotics are the best.  But for ambulatory folks going to work, some less intense ones might be better.

                        We do not disagree fundamentally.  Just on very minor details.

                        Warmest regards,

                        Doc

                        "It is not the content of the post, it is the name recognition that makes the Rec List"

                        by Translator on Thu Jun 11, 2009 at 08:18:28 PM PDT

                        [ Parent ]

                        •  It sucked when I had to quit! ;-) (3+ / 0-)

                          But to give you an idea - my friend with the bad back - and I'm not making this up - was prescribed, each day:

                          Three 40 mgs Oxycontins
                          Three 80 mgs Oxycontins
                          Three 40 mgs Methadone

                          He was also prescribed up to eight, 5 mg immediate-release oxycodone pills (not time-released like Oxycontin) for "breakthrough pain" each day.

                          I figured this was almost a half a gram of just the oxycodone per day!!

                          I'd go visit him though and while he'd occasionally slur his speech a little, other than that, you couldn't tell he was on that many drugs. He even went back to work doing that much. Of course he had a huge tolerance at that point.

                          This ain't no party. This ain't no disco. This ain't no foolin' around!

                          by Snud on Thu Jun 11, 2009 at 08:26:19 PM PDT

                          [ Parent ]

                          •  When I read through all those death reports (2+ / 0-)
                            Recommended by:
                            Snud, Translator

                            I noticed that quite a lot of the reports referenced a previous injury requiring pain meds. We found that a lot of folks had initially developed a dependence on prescribed drugs, and switched to heroin because it is cheaper.

                            We are seeing a huge increase in kids using prescribed opioids. They don't realize that the drugs they are taking are in fact similiar to heroin. They think they are safe because they find them in Mom's medicine cabinet.

                            We have a number of docs in our community who are well known for overprescribing pain meds. And the psychiatrist who comes to the jail has huge numbers of the inmates on Seroquel.

                          •  People found out real quick (2+ / 0-)
                            Recommended by:
                            Translator, TheFatLadySings

                            that, despite what Perdue Pharma (the manufacturer) claimed, Oxycontin was very addictive, even when taken as prescribed.

                            They went on an aggressive marketing campaign and told doctors that it really wasn't addictive at all because it's time-released. Thus there was no quick onset or "rush" when one took it.

                            Well... people learned they could crush, snort, inject and even smoke it to get that rush.

                            But even if they didn't, it's not just the rush that's addictive. So what if it takes an hour to feel good or 20 seconds - you still want to keep feeling good.

                            This ain't no party. This ain't no disco. This ain't no foolin' around!

                            by Snud on Thu Jun 11, 2009 at 09:19:37 PM PDT

                            [ Parent ]

              •  I do not think that we have a fundamental (2+ / 0-)
                Recommended by:
                Snud, TheFatLadySings

                problem with each other, just a difference in opinion.  I will do further research.  Please do the same.  Links would be appreciated.  You have my email in my profile.

                These kinds of debates are valuable.  I suspect that the truth is sort of in the middle of each or our opinions.

                Warmest regards,

                Doc

                "It is not the content of the post, it is the name recognition that makes the Rec List"

                by Translator on Thu Jun 11, 2009 at 07:54:17 PM PDT

                [ Parent ]

        •  One fly in your ointment. (2+ / 0-)
          Recommended by:
          Snud, TheFatLadySings

          Lortab ASA is scheduled that same, but has the less toxic aspirin in it.  How do you explain that?

          Warmest regards,

          Doc

          "It is not the content of the post, it is the name recognition that makes the Rec List"

          by Translator on Thu Jun 11, 2009 at 07:22:04 PM PDT

          [ Parent ]

          •  Please check up on me (2+ / 0-)
            Recommended by:
            Translator, TheFatLadySings

            I'm not being cynical, I promise.

            The formulations are Schedule III because the DEA knows that it helps prevent abuse - pure and simple.

            The "pure" medications: oxycontin, oxymorphone (dilaudid), morphine... all are Schedule II drugs.

            The tylenol, APAP, caffeine are looked at by the DEA as a way to deter abuse.

            Think what happens if you SNORT tylenol or APAP - let alone inject it.

            This ain't no party. This ain't no disco. This ain't no foolin' around!

            by Snud on Thu Jun 11, 2009 at 07:26:22 PM PDT

            [ Parent ]

            •  Perhaps I am just not as cynical (2+ / 0-)
              Recommended by:
              Snud, TheFatLadySings

              as you, but I do agree that complex mixtures are more difficult to abuse than pure substances.

              Warmest regards,

              Doc

              "It is not the content of the post, it is the name recognition that makes the Rec List"

              by Translator on Thu Jun 11, 2009 at 07:29:41 PM PDT

              [ Parent ]

              •  Another link (2+ / 0-)
                Recommended by:
                Translator, TheFatLadySings

                Here

                McNeil Consumer Products Co., a subsidiary of Johnson & Johnson, the company that manufactures Tylenol, has added new warning labels about acetaminophen's potential for damaging the liver, especially when the drug is mixed with alcohol.

                The DEA's prescription-drug classification system is based on the potential for abuse. Schedule I drugs include heroin and Ecstasy, which are both illegal in the United States. Schedule II drugs include powerful painkillers, such as codeine, morphine and Demerol. Cocaine is a Schedule II drug because it has some legitimate medical applications in hospital settings. Schedule III drugs include hydrocodone and anabolic steroids.

                Schedule III drugs are easier to prescribe and ultimately easier to get. A doctor is permitted to phone in a Schedule III prescription refill to a pharmacy. Schedule II refills may only be written after the doctor re-examines the patient. The DEA also requires more stringent record-keeping of Schedule II prescriptions, and it tracks how many each doctor writes.
                Florida, another state battling the hydrocodone epidemic, tried last year to reclassify the drug as a Schedule II. But the new rules were quickly derailed by protests from pharmacists, physicians and patients who said it would make it unreasonably difficult for people to manage day-to-day pain. Florida's attorney general took the unusual step of passing an emergency ordinance, restoring hydrocodone's status as a Schedule III drug.
                Nine years ago the Nevada Board of Pharmacy considered moving hydrocodone to Schedule II, but ended up voting against the plan, according to its attorney, Louis Ling.

                The argument that "carried the day" for the board was doctors' testimony that moving hydrocodone to Schedule II would make it unreasonably difficult for patients in rural areas to get refills, Ling said.

                This ain't no party. This ain't no disco. This ain't no foolin' around!

                by Snud on Thu Jun 11, 2009 at 07:37:26 PM PDT

                [ Parent ]

              •  Not more difficult, just more dangerous. (3+ / 0-)
                Recommended by:
                Ice Blue, Snud, Translator

                I oversee jail-based substance abuse treatment programs. Every time we pull heroin off the streets, our overdose rate spikes. Addicts begin mixing anything they can get their hands on when they are desperate.

                I have long been an opponent of anti-drug strategies aimed at removing a specific drug from the street because it produces bad policy. We need to combat addiction, not specific drugs. Heroin isn't an immigration issue, but it is often treated as such.

                I know I am not being very articulate at the moment. But I hope you are right, and there is no policy to "prevent" abuse by making it easier for addicts to experience liver damage.

                •  Good point which is why (3+ / 0-)
                  Recommended by:
                  Ice Blue, Translator, TheFatLadySings

                  I agree it's a rather nefarious - and to use Doc's word, which I agree with - cynical practice.

                  And you're right; it doesn't prevent someone from snorting or shooting up Lortabs and I suspect a lot of hospital admissions happen from idiots doing just that.

                  One reason Oxycontin got such a bad rep was precisely because it was easy to crush it, snort it and/or shoot it up - something the manufacturer's didn't intend but nonetheless happened. One BIG reason: No tylenol is in Oxycontin.

                  However, many people who are addicted to narcotics aren't stupid. They know they can't shoot up or snort a Lortab without ending up needing a liver transplant.

                  Hence there are internet forums like these and these.

                  This ain't no party. This ain't no disco. This ain't no foolin' around!

                  by Snud on Thu Jun 11, 2009 at 08:02:12 PM PDT

                  [ Parent ]

                  •  Maybe we should all be reading these just (2+ / 0-)
                    Recommended by:
                    Snud, Translator

                    so we can know how to safely take pain meds for our ear infections.

                    It strikes me as absolutely absurd that I can't just go to my primary care doc and know I'm getting a safe pain drug. I have to get on the internet to make sure nothing is mixed up in my drug, and then read a comment thread on the bad drug I'm trying to avoid so I can find an underground link showing me how to get that drug out of my pain meds????

                    Our health care system is even more screwed up than I realized. It doesn't actually matter whether acetaminophen is added to prevent abuse or increase effect. It matters most that I don't know what I'm taking.

                    Thank you both for the informative comment thread.

                    •  I am not sure that you really want to get me (3+ / 0-)
                      Recommended by:
                      Ice Blue, Snud, TheFatLadySings

                      started on this topic.

                      Medical mistakes cost thousands, if not hundred of thousands, of lives in the United States every year.  Many of them have to do with mistakes in a hospital setting.  Go to the CDC site and look for it.

                      I would never allow a loved one to spend the night in hospital alone.  You would be revolted at the mistakes that happen.  I am not kidding, either.

                      Warmest regards,

                      Doc

                      "It is not the content of the post, it is the name recognition that makes the Rec List"

                      by Translator on Thu Jun 11, 2009 at 08:23:19 PM PDT

                      [ Parent ]

                      •  Amen. I had an old friend (3+ / 0-)
                        Recommended by:
                        Ice Blue, Translator, TheFatLadySings

                        die in the hospital from the saddest thing: He had a heart catheter. He was doing OK until a nurse came in and leaned over his bed to mess with something. She inadvertently yanked out his heart catheter, killing him almost immediately.

                        I'm sure she felt terrible but I've seen some things first hand going on in hospitals that would curdle milk.

                        This ain't no party. This ain't no disco. This ain't no foolin' around!

                        by Snud on Thu Jun 11, 2009 at 08:31:39 PM PDT

                        [ Parent ]

                    •  Always look up your meds (3+ / 0-)
                      Recommended by:
                      Translator, eyesoars, TheFatLadySings

                      I never take anything without reading up on it first. Another reason the Internet is a great thing!

                      It's not hard to make informed decisions once you've spent a few minutes reading up on something. If there's any doubt, get a second opinion.

                      This ain't no party. This ain't no disco. This ain't no foolin' around!

                      by Snud on Thu Jun 11, 2009 at 08:29:27 PM PDT

                      [ Parent ]

            •  Want to do a diary on the topic for the series? (2+ / 0-)
              Recommended by:
              Snud, Translator

              I am especially interested if you can link to anything that might verify this claim.

              We have some peculiar drug policies in this country...and now, I am referring to policies directed at preventing abuse.

          •  Please see... (2+ / 0-)
            Recommended by:
            Translator, TheFatLadySings

            This link:

            Hydrocodone is always combined with acetaminophen/ibuprofen/antihistamine as a prescription. The dose of acetaminophen may vary from 350-650 mg. The dose of hydrocodone may vary from 5-15 mg. Various combination of this mixture are available. Hydrocodone is usually taken 3-4 tmes a day to relieve moderate or severe pain. The dose of hydrocodone should not exceed more than 40 mg in a day and the dose of acetaminophen should not exceeed 3-4000 mg per day (8-12 tablets per day).

            In the United States, pure hydrocodone is rarely prescribed and is considered a Schedule 2 drug, requiring DEA certificate for prescription. Hydrocodone when it is prescrbed with acetaminophen is classified as a Schedule 3 drug and availble only with a prescription.

            This ain't no party. This ain't no disco. This ain't no foolin' around!

            by Snud on Thu Jun 11, 2009 at 07:29:41 PM PDT

            [ Parent ]

            •  Ummmmmm, you sort of contradicticed yourself. (2+ / 0-)
              Recommended by:
              Snud, TheFatLadySings

              Please allow me to quote.

              Hydrocodone is always combined with acetaminophen/ibuprofen/antihistamine as a prescription.

              That opens your comment, then you say

              In the United States, pure hydrocodone is rarely prescribed and is considered a Schedule 2 drug, requiring DEA certificate for prescription. Hydrocodone when it is prescrbed with acetaminophen is classified as a Schedule 3 drug and availble only with a prescription.

              Always is not the same thing as rarely.  Sorry to pick these bones, but one is not the same as the other.

              Warmest regards,

              Doc

              "It is not the content of the post, it is the name recognition that makes the Rec List"

              by Translator on Thu Jun 11, 2009 at 07:39:49 PM PDT

              [ Parent ]

              •  I didn't write that but I'll try to explain (2+ / 0-)
                Recommended by:
                Translator, TheFatLadySings

                Hydrocodone is, 99% of the time, prescribed in a mixture with tylenol, aspirin, caffeine and/or other compounds.

                However it's possible to obtain pure hydrocodone from a compounding pharmacy.

                A compounding pharmacy can (theoretically) mix you up a batch of pure hydrocodone - assuming a doctor was willing to prescribe it and the DEA would let him or her.

                So that's the distinction. And if a doctor prescribed it, pure hydrocodone would be a Schedule II drug; could not be phoned in and you'd need a written prescription.

                If I'm not mistaken, the DEA (at least used to) insist on at least 50 mgs of tylenol even if a compounding pharmacy was filling a special prescription for hydrocodone.

                Ask yourself why they'd do that. They do it because they know tylenol will kill you if you take too much. They're not worried about your pain or fever! ;-)

                This ain't no party. This ain't no disco. This ain't no foolin' around!

                by Snud on Thu Jun 11, 2009 at 07:46:18 PM PDT

                [ Parent ]

                •  Part of what's confusing me here is that today (3+ / 0-)
                  Recommended by:
                  churchylafemme, Snud, Translator

                  my doc told me he could not call in Lortabs to the pharmacy and he gave me a written script. Also, I had made a comment about wanting to avoid acetamenophen. He's generally an extremely knowlegable man.

                  How well known is it that lortab and percocets contain acetaminophen? Why would he say he can't call in lortabs?

                  I can't seem to think very clearly tonight. Forget about proper spelling! Am I garbling what you two are saying?

                  •  Look and see it if is (2+ / 0-)
                    Recommended by:
                    Snud, TheFatLadySings

                    Lortabs or Lortabls ASA.  There is a difference.

                    Warmest regards,

                    Doc

                    "It is not the content of the post, it is the name recognition that makes the Rec List"

                    by Translator on Thu Jun 11, 2009 at 07:56:59 PM PDT

                    [ Parent ]

                    •  Hydrocodone APAP. (2+ / 0-)
                      Recommended by:
                      Snud, Translator

                      Now I have to go read through the comment thread to see what that means because I can't remember.

                      •  You got the (1+ / 0-)
                        Recommended by:
                        TheFatLadySings

                        acetaminophen ones.  Go back to your physician and rid yourself of frustration with his ignorance.  He should write you a better prescription, and reverse both charges  for office calls, and offer to pay for the prescription that he foolishly made.  Hold his feet to the fire, and if he is not very helpful, offer to publish his name, address, and specialty here.

                        I suspect that he will buy the drugs back and poison other patients with them, calling them "free samples", write you a new prescription, and never want to see you again.

                        Warmest regards,

                        Doc

                        "It is not the content of the post, it is the name recognition that makes the Rec List"

                        by Translator on Thu Jun 11, 2009 at 08:28:05 PM PDT

                        [ Parent ]

                        •  He's really a very nice man and a good (1+ / 0-)
                          Recommended by:
                          Translator

                          physician. None of that is actually necessary. I'll just talk to him about the issue.

                        •  please (1+ / 0-)
                          Recommended by:
                          Translator

                          I am concerned about the comment that TFLS's doc couldn't call in a script for Lortab, but there are some variations in state laws, too.

                          But the doc cannot buy the drugs back. The doc didn't dispense the drugs, so can't buy them back. And it is illegal to give out "samples" of narcotics, except in very, very rare cases (the clinic I worked in did so on an extremely limited and highly regulated way for patients being treated with suboxone.)

                          Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

                          by stitchmd on Fri Jun 12, 2009 at 12:35:21 AM PDT

                          [ Parent ]

                    •  ASA is aspirin instead of tylenol (2+ / 0-)
                      Recommended by:
                      Translator, TheFatLadySings

                      But the DEA looks at it the same: Their logic is no one will knowingly snort or shoot up aspirin, caffeine or tylenol in any large quantity. So, these compounds get Schedule III status. It's that simple.

                      This ain't no party. This ain't no disco. This ain't no foolin' around!

                      by Snud on Thu Jun 11, 2009 at 08:07:18 PM PDT

                      [ Parent ]

                  •  Unless your state law prohibits it (3+ / 0-)
                    Recommended by:
                    stitchmd, Translator, TheFatLadySings

                    There are no federal laws that prohibit calling in a Schedule III drug over the phone.

                    I'm not aware of a state that prohibits it but NY has some pretty strict prescribing laws.

                    Your doctor may have been mistaken or not telling the truth.

                    Percocet for some reason was deemed "too fun" even with the tylenol and/or aspirin. (Percocet vs Percodan) and are still considered Schedule II and cannot be phoned in. They contain oxycodone which, even when mixed with other compounds, is always a Schedule II.

                    This ain't no party. This ain't no disco. This ain't no foolin' around!

                    by Snud on Thu Jun 11, 2009 at 08:05:32 PM PDT

                    [ Parent ]

                    •  Hmm... (2+ / 0-)
                      Recommended by:
                      Snud, Translator

                      There would be absolutely no reason for him to lie about it and I know him quite well. He's an honest guy.

                      Awhile back, I released a report to the press about overdose deaths in our county, pointing out very high rates of drug mixing, often involving pharmaceuticals. It caused a big stir. At the time, the overdose deaths were being labelled "heroin deaths." The Department of Health epi team produced their own study a few years later, after a change in Governors, and determined we needed stricter controls in our state on pharmaceuticals. It became harder to obtain narcotics. I have a feeling that one of the changes was controls on calling in certain scripts. In fact, now that my controlled substances are wearing off, I'm almost sure of it.

                      So inadvertently, I may have been the cause of my doc's inability to call in my script!

                      •  You can check your state laws (2+ / 0-)
                        Recommended by:
                        Translator, TheFatLadySings

                        But again, I don't think the Fed cares about calling in a Schedule III drug over the phone. AFAIK, Lortab in any formulation (tylenol or aspirin) is Schedule III.

                        Little known trivia: You can even phone in a Schedule II drug... as long as you produce a written prescription within 24 hrs. But that kind of defeats the purpose of phoning it in!

                        This ain't no party. This ain't no disco. This ain't no foolin' around!

                        by Snud on Thu Jun 11, 2009 at 09:23:49 PM PDT

                        [ Parent ]

    •  I am going to disagree with you here. (3+ / 0-)

      I think that this is a very cynical statement, and I do not believe it.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 07:20:23 PM PDT

      [ Parent ]

    •  I'd really like to see links on this (1+ / 0-)
      Recommended by:
      Translator

      first of all, it would not make sense to add acetaminophen to keep people from using the narcotics in an abusive way, because there are no symptoms of acetaminophen toxicity until it's too late to do much, and most people don't know about the toxicity of acetaminophen (hopefully the word is getting out.)

      Narcotics are often combined with acetaminophen because of reasons of potentiation of effect, which is well documented, and can actually help decrease the necessary narcotic dose. Acetaminophen is combined with codeine, with hydrocodone, and with oxycodone - which is also known as Percocet, Roxicet, and other names and is still a schedule II drug.

      Schedule III drugs can often be called into a pharmacy unless state laws prohibit it, but there have also been increased restrictions at the federal level for prescribing Schedule III and Schedule IV drugs. For example, although there has been a push toward electronic prescribing, these drugs are not allowed to be prescribed electronically; they must be faxed, and there are some limitations to e-prescribing for these drugs.

      Schedule II drugs cannot be faxed or called in; there must be a tamper proof, verifiable written prescription for these medications.

      Yes, there is potential for abuse, and one of the biggest fears with a Percocet overdose is not necessarily the narcotic overdose but the acetaminophen toxicity.

      But the DEA doesn't add the acetaminophen to the drugs to increase the toxicity.

      Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

      by stitchmd on Fri Jun 12, 2009 at 12:46:16 AM PDT

      [ Parent ]

  •  This is good info to know, Doc. (2+ / 0-)
    Recommended by:
    Translator, TheFatLadySings

    I usually avoid taking any kind of medication during headaches or fevers. I have a high tolerance to pain, so I don't usually get bad enough to need it, but it's good to know there's a medical reason not to as well.

    Obama doesn't need cheerleaders. (-10.00,-8.87)

    by Texas Revolutionary on Thu Jun 11, 2009 at 06:56:14 PM PDT

  •  Another cause of acetaminophen (8+ / 0-)

    poisoning is poor treatment of chronic pain syndromes and poor communication between doctors.

    Acetaminophen (APAP as it is often abbreviated, confusingly) is in many prescription medications as well.  Vicodin, Tyco, Percocet, Lortab, to name a few.  

    It may not be unusual for a patient with chronic pain to see his primary doctor and receive an rx for vicodin with the warning not to exceed eight tabs a day (four grams of APAP right there).  Then a visit to the orthopedist for an rx for Percocet with the advice, "only four a day" (another 2 grams of APAP). Perhaps a visit to the dentist for a toothache: "Don't take more than six of these Tycos a day." (Another three grams of APAP). And finally back home where uncontrolled pain (Yes, I know this is a lot of pain drugs.  I'd be unconscious, but chronic pain patients develop tolerance to the opiates in these medications) where a few more Tylenol, say eight a day (another four grams) as "I'm not exceeding the limit of what any of the doctors told me, and none of these other bottles contain acetaminophen, just APAP, whatever that is..."

    And it's good night liver.

    But watch out, aspirin and ibuprofen can be dangerous too.  Be careful with drugs!

    Dr. Aaron Roland is a family physician in Burlingame, CA.

    by doctoraaron on Thu Jun 11, 2009 at 07:00:32 PM PDT

    •  What's the issues with ibuprofen? (2+ / 0-)
      Recommended by:
      Translator, TheFatLadySings

      I'm the calm type, so it's not that worry much about this stuff normally.  But what's the issue with ibuprofen.

      From what I'm reading, APAP (thanks for saving me some typing) is not really good as an anti-inflammatory in any case.  But even granting this, when would you prefer APAP to ibuprofen?

      "If another country builds a better car, we buy it. If they make a better wine, we drink it. If they have better healthcare . . . what's our problem? "

      by mbayrob on Thu Jun 11, 2009 at 07:23:54 PM PDT

      [ Parent ]

    •  You make my first recommendation very well. (2+ / 0-)
      Recommended by:
      TexDem, TheFatLadySings

      Take it out of combination products.  Right there you prevent all of those accidental poisonings.

      And I also agree, other drugs are also not without their hazards.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 07:25:38 PM PDT

      [ Parent ]

    •  That's why it's a good idea to (4+ / 0-)

      use only one pharmacy. They do a better job of knowing what and how much of you're using than the doctors             do. (multiple). Of course that won't help with the over the counter stuff. Thanks for the APAP info. I can't believe after nearly 60 years of living that I didn't know what that meant!

      music- the universal language

      by daveygodigaditch on Thu Jun 11, 2009 at 07:51:51 PM PDT

      [ Parent ]

    •  And NO ALCOHOL! (1+ / 0-)
      Recommended by:
      sberel

      Alcohol consumption substantially increases the toxicity of acetaminophen.  If you consume alcohol regularly, you should not take acetaminophen, even after being 'dry' for a week or more.

      Regular alcohol consumption changes the preferred metabolic pathways for ibuprofen, pushing it to a pathway that creates more (liver-)toxic metabolites.  It's a really nasty way to go.

      /es

  •  I'm just astounded that when you buy (3+ / 0-)
    Recommended by:
    Translator, TheFatLadySings, freesia

    an otc drug, the ingredients are all listed yet when you get a prescription you are given zip info for what you are ingesting. Does this make any sense to anyone?

    music- the universal language

    by daveygodigaditch on Thu Jun 11, 2009 at 07:42:23 PM PDT

  •  Your Biggest Actual Problem With it (2+ / 1-)
    Recommended by:
    sberel, Translator
    Hidden by:
    TheFatLadySings

    Seems to be that it's bad for you if you overdoes on it or mix it with alcohol.  The reason it's the number one cause of calls to poison control centers isn't that it's a dangerous drug, it's that Americans are lazy and stupid.  The people who get too much because they're mixing medications should be making sure all their doctors know all the medications they are on.  The people who are mixing it with alcohol are ignoring existing instructions not to, and the people who are willingly overdosing get whatever they have coming.

    The only people who would follow your advice and completely avoid it are the same people who are smart enough not to kill themselves trying to take it... they're going to follow directions, not mix it with alcohol, and have the sense to make sure ANYBODY who is prescribing medicine for them knows all the medicines they are on.

    None of the medications you mentioned for pain should be OD'd on or mixed with alcohol.  If Acetaminophen works for someone's pain, and they're taking it responsibly, they should continue taking it responsibly, right?

    Senator Inhofe? If you're still wondering? He's on my side.

    by TooFolkGR on Thu Jun 11, 2009 at 08:26:55 PM PDT

  •  FWIW (0+ / 0-)

    Acetylcysteine is an awesome hangover preventative/cure.

  •  This is an excellent diary. (1+ / 0-)
    Recommended by:
    Translator

    I avoid like the plague the Lortab/Vicodin stuff, because it has adverse effects on my IBS, and I figure that if I need the harder stuff to someday deal with cancer pain or something, I'd like to be clear. Tramadol works for the chronic pain just fine, and I can take the dosage I am prescribed when I have high pain days.

    Acetaminophen is okay, but not as good for pain as ibuprofen is for me. It makes my husband's diverticulosis act up, so he avoids it when he can. So beyond keeping some Vicodins in the house because if one of us breaks something we'll need it to get through the night before we can go see someone about it, we really don't keep it around.

    •  I have some aspirin and some ibuprofen (1+ / 0-)
      Recommended by:
      Alexandra Lynch

      that I bought after I burnt my hand.  I took one, hmmmm, maybe two weeks ago.

      Warmest regards,

      Look for me Sunday on my post.

      Warmest regards,

      Doc

      "It is not the content of the post, it is the name recognition that makes the Rec List"

      by Translator on Thu Jun 11, 2009 at 10:26:28 PM PDT

      [ Parent ]

    •  tramadol can also be combined with acetaminophen (2+ / 0-)
      Recommended by:
      Alexandra Lynch, Translator

      brand name is Ultracet. Just sayin', to make people aware.

      Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - W S Coffin

      by stitchmd on Fri Jun 12, 2009 at 12:52:16 AM PDT

      [ Parent ]

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