
Use Only as Directed - tokenadult
http://www.propublica.org/article/tylenol-mcneil-fda-use-only-as-directed
======
JacobAldridge
So today I learnt that paracetamol is also called acetaminophen. I'd always
assumed Tylenol in the US was functionally equivalent to Panadol in Australia
- ie, a brand name used in place of a drug name referring to the most common
form of over-the-counter pain relief.

When I started reading this article I was surprised to learn Tylenol had a
different active ingredient, and almost tuned out to the warning because I've
never encountered acetaminophen in the wild. But my linguistic assumption
compelled me search further, and uncover the connection.

~~~
ars
> I'd always assumed Tylenol in the US was functionally equivalent to Panadol
> in Australia

Your assumption is correct.

> I was surprised to learn Tylenol had a different active ingredient

??? It doesn't. Unless you mean it has a different _name_ for the active
ingredient.

~~~
JacobAldridge
_" So today I learnt that paracetamol is also called acetaminophen."_

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jonnathanson
Side note, but I learned about the dangers of acetaminophen when I was on
Vicodin while recovering from a major surgery a few years back. Back then, a
lot of Vicodin tablets (and generics) had doses as high as 500mg of
acetaminophen per pill, and I could have sworn I saw them go as high as 750 in
some instances. (The FDA has since lowered the cap to 350, in light of the
huge risk of liver damage).

The drug was almost banned from the U.S. market entirely in 2009, and not
because of the hydrocodone. The acetaminophen is more deadly than the
hydrocodone in the quantities consumed per day.

~~~
seszett
Do 500 mg or even 750mg sound that high?

Paracetamol (the non-US name of acetaminophen) here in France is usually
available either in 500mg or 1g doses, and Wikipedia seems to say we had 6
deaths in 1990, and the number has been stable since then, so more than five
times less than the US relative to population size.

So, I'm not sure that dosage is the most important factor here.

~~~
shubb
How many grams in total do you get in a pack?

In a lot of Europe (certainly UK, I heard also France), you can only buy 16
pills (about 8g) at a time, unless your doctor writes you a ticket.

The pills themselves may contain a lot of chemical, but the whole pack doesn't
contain enough grams for a successful impulsive suicide. You would need to go
to a second drug store, by which time you'd probably decide not to do it.
Hence the reduction in death rate.

The problem of liver damage due to chronic over use continues .

~~~
seszett
Right, I had not thought about this aspect of things, both the 500mg and 1g
tubes I have at home contain a total of only 8g.

It doesn't seem difficult to accumulate more than 8g at home over time though,
I'm not a big consumer of these and I have 12g at home, in three tubes. I
remember my grand parents having _a lot_ more packs at their place.

------
asveikau
Also the topic of the latest This American Life:
[http://www.thisamericanlife.org/radio-
archives/episode/505/u...](http://www.thisamericanlife.org/radio-
archives/episode/505/use-only-as-directed)

Since it is Sunday and that's when they post the MP3s I listened to some of it
today ... I had known of the dangers but had no idea how easy it was to get
into dangerous territory. Interesting presentation as well.

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gliese1337
I have little sympathy for people thinking "oh, it's safe, so it must be safe
to take more than the maximum recommended safe dose", but that might be
partially because I'm married to a nurse. If I try to be a little more
objective about it, I suppose its sensible given how prevalent the drug is and
how little you ever _hear_ about people having problems with it- you wouldn't
really assume that overdosing would be _that_ dangerous.

When your pain is bad, it is tempting to just keep taking more drugs until it
starts working, and everyone knows (er... everyone I know; again, probably
biased 'cause married to a nurse) you're not supposed to take too much
ibuprofen 'cause it's bad for your stomach, so might as well take tylenol.
Fortunately, one of the genuine good features of acetaminophen is a lack of
negative interactions with other drugs, so the safe way (as far as I know /
have experienced, not a medical professional, don't take my advice, etc.,
etc.) to assuage that temptation is to vary the types of painkillers you use-
little bit of ibuprofen, little bit of tylenol, and unless it gets _really_
bad (at which point you should probably be seeing a doctor and not self-
medicating anyway), that generally keeps you within safe limits for both (if
you wanna add more types to the rotation, though, you do have to do some
research and make sure that the additions don't cause bad interactions or have
similar mixtures of active ingredients; e.g., if you take Aleve, that counts
towards your total ibuprofen dosage limits).

~~~
cmccabe
I don't subscribe to the belief that people deserve to die for not doing
exhaustive research on the over-the-counter medications they take. You might
want to rethink your position, since you apparently didn't do enough research
yourself when you said that acetaminophen has "a lack of negative interactions
with other drugs." Acetaminophen interacts with a lot of commonly taken drugs,
such as alcohol, ephinedrine, and lomitapide, not to mention things that most
people don't consider drugs like white grapefruit juice.

The reality is, unless you're a child or a teenager, you should just take
aspirin. It won't damage your liver or give you an ulcer like acetaminophen or
ibuprofen. And it is actually an anti-inflammatory, not just a fever reducer
and mood-altering drug.

~~~
waqf
Aspirin does cause ulcers. If you have references showing that ibuprofen is
more dangerous (or even differently dangerous) than aspirin I would be
interested to see them.

~~~
cmccabe
That's a good point. I don't really have any hard information on which is more
dangerous in terms of ulcers. I find conflicting information online. One thing
is for sure: you should NOT take either aspirin or ibuprofen on an empty
stomach. Always eat something first.

I tend to lean towards aspirin for a few reasons. It's older (100 years versus
30 years old) so we've had more time to figure out what other side effects it
has, as well as interactions with other drugs. The blood thinning effect
reduces the chance of heart attack or stroke (while it's in your system),
which is always nice. There are some studies which seem to show that aspirin
has anti-cancer properties, but I'm not sure if I believe them, because they
have not proposed a mechanism of causation. Finally, ibuprofen seems to be
sold in higher doses in general and have a more intense effect, which isn't
really want I want. I just want something that does the minimum most of the
time.

~~~
nknighthb
Do you understand that most people do not take painkillers for more than a few
days at a time, and rarely at anything like the maximum daily dose?

You're worried about effects that occur with chronic high dosages. That's not
the typical use-case.

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dmckeon
I would not describe the ~40% of acetaminophen overdoses in the US that are
attempted suicides as "accidental".

[http://onlinelibrary.wiley.com/doi/10.1002/hep.20948/pdf](http://onlinelibrary.wiley.com/doi/10.1002/hep.20948/pdf)

~~~
cynwoody
One notable case in point was the suicide of Dr Bruce Ivins, senior biodefense
researcher at the United States Army Medical Research Institute of Infectious
Diseases (USAMRIID) in Fort Detrick, Maryland.

By 2008, Ivins had found himself on the FBI's short list in the Amerithrax[1]
investigation. No autopsy was ordered[2], due to the medical examiner's blood
tests which revealed an overdose of acetaminophen and codeine.

[1][http://en.wikipedia.org/wiki/2001_anthrax_attacks](http://en.wikipedia.org/wiki/2001_anthrax_attacks)

[2][http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aKQxd...](http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aKQxd_8Ywgpg&refer=home)

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gadders
Related: Fall in paracetamol deaths 'linked to pack limits'

Deaths from paracetamol overdoses fell by 43% in England and Wales in the 11
years after the law on pack sizes was changed, according to a study.

[http://www.bbc.co.uk/news/health-21370910](http://www.bbc.co.uk/news/health-21370910)

~~~
lewispollard
I don't have any sources but I think education about paracetamol was improved
too, most people seem to be aware of the risks to the liver and know not to
take it when consuming alcohol.

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mattip
While every death is a tragedy, 150 per year makes the phenomenon quite the
outlier. For perspective, cancer takes over 500,000 lives a year in the US
[1]. And lightning kills around 50 [2].

[1]
[http://www.cdc.gov/nchs/fastats/lcod.htm](http://www.cdc.gov/nchs/fastats/lcod.htm)

[2]
[http://www.lightningsafety.noaa.gov/fatalities.htm](http://www.lightningsafety.noaa.gov/fatalities.htm)

~~~
x0x0
the difference, unlike cancer, is we know how to nearly completely prevent
those 150/year (and 70k associated hospitalizations)... it's just it puts a
big dent in a private company's earnings and we have the best congress that
money can buy. fta

    
    
       The German government reported four deaths from acetaminophen poisoning in 
       2010, the same year the CDC put the American total at 321. The U.S. 
       population is four times that of Germany.
    

Germany has strict controls on acetaminophen.

~~~
iopq
Yet 85000 people die each year of alcohol abuse. Legalizing marijuana as a
substitute for alcohol would save thousands of lives each year. I would pick
my battles, this issue seems very minor in comparison to the real problems.

~~~
cmccabe
MDMA would be a much better substitute for alcohol, since it doesn't cause
long-term cognitive impairment or lung cancer.

Of course, I don't encourage anyone to use drugs that are currently illegal,
since what you're getting is not pure.

Either way, it's off-topic.

~~~
dagw
_MDMA would be a much better substitute for alcohol_

I think you are seriously misunderstanding the normal use case for alcohol.

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belorn
When using statistics, it needs to be done with more care. This is a typical
example where the article fails to support its main argument because of not
using statistics correctly:

> The amount of acetaminophen these patients had ingested was close to the
> recommended daily dose of 4 grams. The median was 6 grams per day — a
> surprise, because the toxic dose was thought to be between 10 and 15 grams,
> Erush said. She also found that most of these patients had other risk
> factors, such as chronic alcohol use.

That is like saying: The median speed in fatal accidents are 10% over the
speed limit, with most involved drivers having other risk factors such as
chronic alcohol use.

Without separating out the factors, we can't say how much higher risk of an
fatal accident a 10% over the speed limit might cause. The information is
simply not there. I would have liked that the article told me about the
increased risk that 6 grams per day might give _by itself_. Combining 6 grams
with alcohol is a bad idea, and is as obvious as being drunk and speeding. The
article really shouldn't focus on those kind of scenarios, and it weakens the
main argument they are trying to make.

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ars
That's why I buy ibuprofen instead. It's safer, except for someone who is
pregnant.

~~~
andrewaylett
Different use cases, surely? I tend to pick my painkillers according to the
nature of the pain.

~~~
ars
They seem equivalent to me as far as the type of pain.

How would you distinguish them?

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gonzoisme
150 or 1500?

~~~
bobbles
It's 150 a year, but the post starts with 'during the last decade'

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goggles99
Far more people in the US die of dehydration every year. I am not saying that
we shouldn't try to save people dying from different causes, but please -
people have to use at least basic common sense when ingesting drugs.

~~~
Tichy
How does that work - they forget to drink and die?

~~~
brazzy
Usually they have a gastrointestinal infection and lose fluid through diarrhea
and vomiting, i.e. drinking doesn't help. If they don't get it via an
infusion, it can be game over surprisingly quickly.

"You die of dysentry" isn't just a game quirk.

~~~
Tichy
Interesting, although I wonder if "death by dehydration" would be the correct
labeling of those cases.

Like if you are being stabbed through the heart, technically you die of heart
failure.

