Acetaminophen: Miracle Drug or Liver Toxin?

Acetaminophen: Miracle Drug or Liver Toxin?

Today we are reading reports that the Food and Drug Administration (FDA) “assembled 37 experts to recommend ways to reduce deadly overdoses with acetaminophen, which is the leading cause of liver failure in the US and sends 56,000 people to the emergency room annually.”

As a physician who specializes in Pain Medicine for the last 20 years, I routinely order blood work to measure liver function studies at least once/year in those who are taking acetaminophen on a regular basis.

In my experience, everyone I have seen who has liver damage due to taking too much acetaminophen has either intentionally overdosed on acetaminophen or taken large doses of acetaminophen with pre-existing liver disease from other causes, such as Hepatitis C or alcoholic liver disease.

For those with pre-existing liver disease due to Hepatitis C, long term alcohol abuse, or other causes, I would recommend that they avoid acetaminophen completely. In my experience, acetaminophen will certainly “pour gasoline on the fire” of any pre-existing liver disease.

As the news reports correctly point out, acetaminophen is contained in many non-prescription medications (such as cold remedies, pain medications) as well as prescription medications (such as Vicodin, Lortab, Lorcet, Percodan, & Percocet).

Some people with severe pain conditions take more than the recommended maximum dosage of acetaminophen (two 500mg tablets up to 4 times daily) in order to get relief from their pain without going to a doctor or having to take prescription medications. I would certainly recommend against this.

BOTTOM LINE

If you have liver disease from other causes, such as Hepatitis C, regular alcohol use, or other causes, avoid regular use of significant amounts of acetaminophen and get blood work to track changes in liver function studies.

If you do not have liver disease, occasional use of acetaminophen is safe as long as you’ve never had an allergic reaction.

If you take acetaminophen on a regular basis, either alone or as an ingredient contained in other medications, speak with your healthcare provider about getting blood work to measure you liver function studies.

If your liver function studies are normal, then there is no evidence that your current intake of acetaminophen is doing harm. If they are elevated, then discuss this with your healthcare provider. Consider stopping acetaminophen & alcohol, and ask your healthcare provider about further investigation into other possible causes of liver disease, including other medications that can cause liver enzyme elevations.

Pain Treatment Outcomes: The “4 A’s”

“Treatment outcomes” is the term used by healthcare providers that refers to benefits as well as side effects that result from a particular treatment, or combination of treatments, at a particular point in time. For chronic pain conditions, one way to categorize these is known as the “4 A’s”:

Analgesia (pain relief), Activities of Daily Living (ability to do things that you want or need to do), Adverse Effects (side effects), and Aberrant Behaviors (behaviors that may be warning signs for a problem with addiction).

The first “A” stands for “Analgesia” which refers to the amount of pain relief from current treatments. The standard measurement for this is the “1 to 10 scale.” Some people find this difficult to use, but it is an important tool for communication between the person who suffers from the pain condition and their treating physician. “10/10” represents “the worst pain you can imagine.” I often suggest that the chronic pain sufferer “imagine that all medication has been stopped--THIS would be 10/10.”
So to assess analgesia, or the amount of pain relief, the question becomes:
“WITH THE MEDICATION YOU ARE NOW TAKING, HOW MUCH LESS THAN 10/10 IS YOUR PAIN LEVEL? HOW MUCH BENEFIT ARE YOU GETTING FROM YOUR MEDICATION?”

The second “A” stands for “Activities of Daily Living, which refers to your ability to do things that you want or need to do. This begins with basic issues of taking care of yourself, and extends to your ability to perform activities as parent, spouse, friend, family member, work, hobbies, & community member, including religious activities. The goal here is for treatment to increase your ability to function in these areas.

Very often there are physical problems with being able to do things that you want or need to do, because some of these activities make pain worse, and may even do physical damage to bones, discs, joints, or soft tissues (tendons, ligaments)

Managing Pain: Nursing Diagnosis & Decision Making presented at Baptist Memorial Hospital Nursing Staff

I enjoyed the opportunity to speak to a group of 40 nurses at Baptist Memorial Hospital in East Memphis regarding an important area of interest to them: how to administer enough narcotic pain medication to relieve suffering, while avoiding potential adverse medical & behavioral effects that these medications can have.


We discussed the nursing decision-making process, which involves not only assessment of the type & severity of the pain, but also the warning signs that additional dosages of narcotic pain might actually result in more side effects than benefits. They received a handout that included signs and symptoms of narcotic side effects, toxicity, & withdrawal.


As with any issue dealt with by healthcare professionals, understanding important aspects of the patient’s recent & past medical history is essential for achievement of best possible clinical outcomes. These include:

• Since your last dose of pain medication, in what way(s) are you feeling better, and in what way(s) are you feeling worse?


• Is this pain relatively recent in onset, or has this been present for months, or even years, prior to this hospitalization?


• Have you been taking pain medication on a regular basis, & for a long time? How much pain medication have you taken in the last week, or the last month?


• Which medication(s) have worked well in the past? Which have had adverse side effects?


• What about non-medication techniques?

Another concern was that some patients seem to request narcotic pain medications in order to feel better emotionally, as well as physically. This leads to the question of whether a particular patient may have a problem with addiction, with or without “real” physical pain. We discussed the warning signs of inappropriate use of these medications by patients, diagnostic criteria for addiction, and how nursing staff can intervene when concerned about this.

We also spoke about different routes of administering medication: IV vs oral, and the importance of making the transition to oral medications as discharge approaches.

One theme that consistently emerged during our discussion was communication. Communication with the patient, getting the point of view of concerned family member(s), keeping physicians informed about issues of concern, and keeping patients informed regarding their decisions about how & when to take or not take narcotic pain medications, including preparation for transition to home after discharge.

As always, the nursing staff enjoyed the opportunity to ask questions & learn about important clinical issues that concern their ability to provide the best possible care to their patients in the hospital, who face difficult & complex illnesses. Their highest concern was to improve their ability to provide the most effective possible treatment, while following the first rule of healthcare: “do no harm.”