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Comment by blinkingled | Hacker News Reader

> He died at a hospital in Seattle. His wife, Cindy Engstrom, said he had injured one of his feet in October, accidentally took too much Tylenol for pain relief and suffered liver damage.

As sad as it is to lose a person at age 55, it's even harder to digest the tylenol induced liver failure part until you experience foot injury/pain. I spent last December in excruciating foot pain that came out of nowhere and the thought of wanting to guzzle down entire bottle of Advil/Tylenol touched my mind at least couple times.

Anyway, RIP. Old interview with him - https://www.youtube.com/watch?v=rjZWUweIIEU

View on HN

Both of my parents are physicians, and both have worked in emergency rooms at some point in their careers. One thing they've taught me is to be cautious about taking too much Tylenol.

At the right dose, Tylenol may well be the safest pain medication we have, even compared to Advil, which can occasionally cause problems if taken regularly over a lifetime. However, the gap between a useful dose of Tylenol, and the amount of Tylenol which will kill you, is relatively small compared to similar medicines.

My parents say they've watched a lot of people die in the hospital from Tylenol overdoses. There is an antidote, but only if you get it in time.

Wow, we recently had a scare with our five year old passed out in her room with a bottle full of Tylenol strewn about. Getting an artery stick on a five year old is one of the most awful things I’ve had to endure, but I wasn’t going to trust a five year old on whether she had taken the pills or not. Turned out she hadn’t taken any! But it was super scary, Tylenol poisoning is no joke, and we have lock boxes for all our medications now.

I'm so glad to hear she is okay.

Amazing how effective those child proof containers are at vexing adults, and how ineffective they are for children.

Adults see a hassle, kids see a challenge. It's almost a counter-incentive.

Or, worse, your kid is that kid that sees it as "Oh, I can open this, I must be a grown up then"

I feel like this applies to every area of life. What happened to us all?

So, then should Advil (ibuprofen) always be taken instead? When is it appropriate to take Tylenol over Advil?

Neither Paracetamol (Tylenol) nor Ibuprofen (Advil) is side-effect free - and thus you should stick to prescribed amounts unless you've received medical advice.

Having said that, given I am not a doctor/clinician/pharmacologist/pharmacist, you can usually alternate them to take a higher dosage of pain relief.

To be clear, the message (which I'm passing on second-hand, I'm not a doctor myself!) wasn't that you shouldn't take Tylenol, just that you need to be careful with the dosage. My father in particular thinks Tylenol is better than Advil if used regularly over decades (although he'd probably say it depends on other health conditions too; both are safe medicines overall.)

IIRC you can take them both on interleaved but overlapping schedules, for those times when the maximum frequency of advil isnt good enough. Check on that before doing it though.

>Check on that before doing it though.

Indeed, but I think it's better to just not post such medical advice at all.

If you're Asthmatic (it's generally not advised to take Aspirin or Ibuprofen as you could be allergic to it), if you have an ulcer, if you're on a blood thinner such as warfarin.

Either is fine as long as you follow the instructions on the bottle.

Ask a doctor. They are qualified to give you the right answer based upon symptoms and medical history.

A lot of things such as OTC cough medicine and some opiods contain the active ingredient of Tylenol so that's a good use case for avoiding it. Ibuprofen has issues of its own, but IIRC it's typically safe to take 2-4x the recommend dose on the bottle, which could be pushing it if you did the same with Tylenol over an extended period (especially if you're a drinker). I've heard anecdotally that if Tylenol were invented today the FDA wouldn't approve it because it's relatively easy to OD.

Meanwhile, doctors I've been to offer out prescriptions for 800mg ibuprofen pretty freely and don't seem too worried about side effects (IMO it's easier to just take a bunch of the smaller ones instead of a single horsepill)

> I've heard anecdotally that if Tylenol were invented today the FDA wouldn't approve it because it's relatively easy to OD.

That seems a little suspect to me. It's a very useful medicine, and a better choice than Advil for some people. And it really is safe at the right dose.

The argument is that the delta between normal use and liver toxicity especially if one adds in a few drinks is pretty small. I have heard the same thing and it's probably not an unreasonable argument. (Or, if approved, it might be a prescription med.)

> Or, if approved, it might be a prescription med.

That seems much more likely—but, very few drugs are approved for OTC use out of the gate! They generally want OTC drugs to have been in use for a long time.

"always" is too much of an absolute. It really depends on a variety of factors, not least if which are other medications you might be on and underlying conditions. For example, ibuprofen doesn't play nicely with prednisone. Or if you have any sort of existing liver problems then acetomenophen is really not a great idea.

If you have a regular doctor, it's probably a good idea to ask which of a few different options are safe for you for occasional use, and probably check in if you find yourself needing something for longer than a few days. (And if you don't have a regular doctor, find one... If you lack insurance, it's still probably worth the money to pay once a year for a physical, and also have a resource that knows your health history that you can consult with. For basic questions, like "does my medical history rule out acetomenophen", most doctor's offices will take a message for the doctor and then call you back with an answer)

No-one here can answer that because the only people qualified to do so (pharmacists, doctors, some nurses) also have a professional duty preventing them.

The answer is "it depends" on your history and any other meds you're taking and also your home situation.

There were also the Tyelnol murders that are I think still unsolved? Did not seem to have stopped people from using it which is a surprise really.

Johnson & Johnson recalled every single bottle of Tylenol and re-designed the packaging. Actually worked out pretty well for the brand and they sold more after the murders than before.

Also that was 38 years ago.

As someone taking a lot of Tylenol after a car accident a week ago, thanks for the advice!

I'll switch to Ibuprofen now. They didn't give me any prescription meds because there were no broken bones, but my chest and left shoulder are in so much pain, specially when I wakeup. Airbags were deployed, and I went from 84 mph to zero when the crash happened (dashcam had the speed on it).

Just make sure you have food in your stomach when you take ibuprofen. I used to take 12 a day in high school to play (badly) at sports and it can do a number on your stomach lining. Iirc the mechanism that causes it to dull the pain also creates stomach acid.

Can't help but think we can't keep doing this to children/young adults...

I also took it daily and heavily in high school during basketball season for shin splints. Probably a couple of years of pulling that mess. I often think back now to how I had a complete system that timed for efficacy, taking a few 30 min before practice then more while suiting up, then even more if I could during and then after practice. I'd alter this timing on game days since practices were walk-thrus, etc.

In some ways it's a relief to hear from someone else with that experience (this was 20 years ago for me).

When I was younger (and stupider) I was prescribed giant 800mg ibuprofen pills for an injury. I wasn't in the habit of eating with them, and ended up burning the end of my esophagus with stomach acid. I could only eat popsicles and slurpees for a couple weeks because it was too painful to swallow anything else.

> Iirc the mechanism that causes it to dull the pain also creates stomach acid.

Maybe it also increase stomach acid production, but my understanding is that the primary problem is that it thins the protective stomach lining.

Ibuprofen is a non-selective inhibitor of the COX enzymes. Inhibiting COX-2 reduces pain and inflammation. Inhibiting COX-1 inhibits stomach lining growth and the clotting process. Pharma has created selective COX-2 inhibitors, but some of those have run into their own problems (blood clots leading to myocardial infarctions in the case of Vioxx patients who weren't also on aspirin, IIRC... though, an increase in MIs would seem to be the natural and obvious side effect of intentionally reducing COX-1 inhibition. IIRC, the increase in MIs was in contrast to the traditional Ibuprofen treatment, not compared to an unmedicated baseline.)

Large doses of vitamin C taken with aspirin or ibuprofen also seem to help with the stomach acid problem. Inspired by a paper on PubMed (so this isn't entirely anecdotal) I tried it and it works for me.

Food also helps but not 100%. IME it does not seem to "soak up" all of the excess acid. Vitamin C is also not 100% but IME more effective than food.

I'm not a frequent or high dose user of NSAIDs, I just seem to have an easily irritated stomach.

If you might be taking Ibuprofen for a while, I encourage you to also look at its long-term-usage side-effects. Probably NBD, but worth keeping in the back of your mind.

It isn't NBD, ibuprofen will absolutely destroy your esophagus. The difference is that ibuprofen is safe once and will kill you over time, but Tylenol is safe over time and will kill you once.

There's a protocol where you switch between them which is okay, but you should get the good stuff if you need it.

not a doctor, but careful with Ibuprofen also, it has its own risks. Paracetamol / Acetaminophen is one of the safest taken at the right levels. You can actually have both at the same time as well.

I've had a doctor friend say that acetaminophen would have never been approved for over the counter use if it were invented today.

Don’t. Just pay attention.

Ibuprofen is awful for your kidneys. You should go back and demand more appropriate pain relief instead of CYA bullshit from a doctor.

Ibuprofen is terrible for other reasons.

If you're taking Tylenol, one thing you can do to help protect against liver damage is to take a milk thistle supplement.

You can also take NAC, which is what they give you for the antidote. As a bonus it's also effective against acne, addictive behavior, and stimulant tolerance.

If that's true, why don't they add it to the Tylenol?

I guess because a good percentage of the population is allergic to milk and dairy products? I know a handful myself.

Milk Thistle[1] is an herb, no dairy.

[1]https://en.wikipedia.org/wiki/Silybum_marianum

They talked about adding NAC to tylenol, which is an antidote for tylenol poisoning.

Problem is, NAC can be quite rough to take - nausea, vomiting, etc.

what ever the medication you use, just read carefully the instructions, there's all the info in there that you need to safely use it. Paracetamol (Tylenol) is perfectly safe as long as you don't cross the recommended dosages.

Talk to you doctor before trying this, but it is usually OK to take both acetaminophen (Tylenol) and ibuprofen (Advil) at the same time.

They work in different ways, so using them together can let you stay well away from a harmful dose of either and still get better pain relief that taking a maximum dose of just one.

I somehow injured my rotator cuff, an injury normally associated with athletes but that I somehow got while sleeping?! With my doctor's permission, I did 1000 mg of acetaminophen every 8 hours and 400 mg of ibuprofen every 4 hours. The later was originally going to be 800 mg every 8 hours, but I asked if I could do it 400 mg every 4.

I’m not a doctor, but yes I’ve done paracetamol/ ibuprofen interleaved with 2 hours gaps between each other when I had very bad flu.

I’m curious why no one here mentioned aspirin though

You still have to be careful with NSAIDs. I have kidney failure but when being diagnosed they presumed it was likely due to NSAIDs but the real reason was finally autoimmune disease. I think they say long term use of NSAIDs is not good for kidneys. For me NSAIDs are entirely excluded. But my nephrologist say Tylenol is fine for long term if I stay within limits. Fortunately I've not had to use it often. And I don't take OTC medicines now without doctor review.

Since I'm on an anticoagulant, I can tell you that the deal with NSAIDs is bleeding: they have anti-platelet properties which can make you more susceptible to bleeding.

My second hand knowledge from a talk with a pharmacist: both paracetamol (tylenol) and ibuprofen are much more dangerous, than I previously believed.

Both have very tight margins between normal dose and overdose. If I remember correctly overdosing is 50% over the normal dose. So take couple more pills a day than it says on the label - and you can land in the hospital.

I was super glad for that info, because I treated instructions more as a suggestion. Now I am much more cautious. _Never_ go above what's instructed, use them as instructed (before/after a meal, etc.), do not mix drugs unless explicitly allowed by your doctor and for the love of god do not mix medicine and alcohol. It's too easy to overdose these common drugs.

The maximum safe dosage of Tylenol is 4000mg; an extra-strength pill is 500mg, and a normal dose is 2 pills, meaning the dose you'd have to take to push the danger zone is 400% over the normal dose.

4000mg in a 24 hour period.

That's true, but the half-life is apparently 2 hours (if you have a normally-functioning liver).

I don't want to downplay it, I just felt like "50%" sort of suggested a single extra Tylenol might kill you, which is very unlikely.

Yes, but Tylenol’s toxicity is due to glutathione depletion. Your body can handle the toxic metabolites with no issue, as long as there isn’t a lot of them.

Once you’ve depleted your liver’s glutathione stores (too much tylenol, too much alcohol, not enough food to replenish glutathione) then the Tylenol becomes very toxic to liver tissue.

But Tylenol’s label says a maximum of 4g per day or 8 extra strength tablets (500 mg each).

From what I’ve gathered, you can detect some liver damage as you get close to 10g per day, but we’re talking mildly elevated ALT/AST enzymes. But if you’re sick, or drink a lot or not eating, you could see serious toxicity at 200% of the maximum daily dose.

> If I remember correctly overdosing is 50% over the normal dose.

No, it's closer to 100% over the maximum daily dose. (maximum daily dose is 4g, toxic dose for a single ingestion is 7.5-10g.)

https://www.health.harvard.edu/pain/acetaminophen-safety-be-...

https://www.medscape.com/answers/820200-27208/what-are-the-m...

Take both to help not overdo the dosing on either. While tylenol can be bad for the liver, like someone else said ibuprofen can wreak havok on your GI system. That's not all -- it can stain or injure your renal system if you overdose it. Tylenol overdoses, if caught in time, can be mitigated by acetylcysteine (as an antidote). I am unaware of any such equivalent for ibuprofen besides dialysis (usually if it gets concentrated enough to cross the blood-brain barrier). That's crummy you didn't get at least a small rx for narcotics for the first few days - there is a time and place for them. Don't forget to make sure the chest pain is not preventing adequate respirations.

My cousin burned a hole in his stomach with Ibuprofen trying to quash some pain that turned out to be metastatic esophageal cancer. (Somehow, he's still alive.) Mind your NSAIDs!

Ibuprofin has the same tight margin and has added effect of weakening your stomach walls.

Paracetamol is usually the safest option. I only take Ibuprofin in serious cases or when there's infection.

Hope you get well soon

Yes, exactly, the dangerous dose is not far past the safe dose.

One of the common causes is that many medicines contain Tylenol/acetaminophen, but don't have it in the name [1]. For example, DayQuil or Alka-Seltzer Plus Cold and Sinus.

People take something like that, then they layer Tylenol on top of it thinking that is the first Tylenol they are taking, and it pushes them into the danger zone.

[1] https://www.healthgrades.com/right-care/chronic-pain/5-medic...

Also, it's important to note that in places more strongly influenced by British English, acetaminophen is known as paracetamol.

I always try to buy individual drugs for this reason. If I want DayQuil, I look at the ingredients on the box, and buy each of them individually. Then I only take the ones I need.

Interesting. When I was a kid, I enjoyed the taste of Tylenol a lot. One night, I elaborated a very bold plan to get the medicine and drink it without my parents seeing. Fortunately, I was caught. Your comment made me realize how lucky I was.

I think this sort of issue is more common than non-medical people realize. It amazes me how often in movies and real life you see people wake up after a night of heavy drinking (sometimes still drunk) and take tylenol or other NSAIDs with liver/drinking warning labels. Or guzzling more NyQuil than they should (contains acetaminophen). The movie industry has cracked down on showing smoking, yet they still show people doing things that could cause liver damage in a unintuitive way.

This seems to be a country-specific lack of awareness. In the UK it's hard to buy large quantities of Acetaminophen/Paracetamol and pretty much everyone is aware that it's dangerous in quantity.

I wish they would ban the codeine boosted Tylenol for this reason. People will take more than prescribed at once because the codeine really knocks the edge off, but they forget about the overdose of Tylenol. If they need codeine, just prescribe that and let patients supplement with reasonable doses of NSAIDS.

That's why the Tylenol is in it: to deter you from getting addicted with the threat of dying.

Better dead than a junkie?

That's the strategy used by prohibition-era denatured alcohol manufacturers who spiked their product with methanol and other toxic additives. Instead of stopping people from using it as surrogate alcohol, it lead to dozens of deaths

https://en.wikipedia.org/wiki/Denatured_alcohol#Toxicity

hahahaha. that opiate addicts are 'persuaded' by threat of dying lol.

opiates are insane in their physiological response and addiction; it's hard to understate the power or explain if you aren't or don't know an addict

Or, they'll take normal Tylenol alongside a number of other products that unbeknownst to them also contain Tylenol, like NyQuil, and overdose that way despite taking a normal dose of each medicine individually.

What should be banned IMO are products which combine acetaminophen/Tylenol with something else.

It's done on purpose as 'anti-abuse'. I think it's about as empathetic as spikes put in areas where the homeless typically sleep.

I don't think I believe that. Firstly, in order for that strategy to be effective, Tylenol's deadliness would have to be widely known, which I don't think it is. Secondly, the "punishment" is that you kill someone.

I agree it sounds strange to use Tylenol like that, but the part about adding something that causes fatal poisoning to spite people who might use it as a vice... that's what denatured alcohol is.

We'd rather make something poisonous than miss out on taxes

When I told that governments happily trade lives for money up to a certain point in one if the discussions on HN I was downvoted to oblivion.

I agree completely, but... https://en.wikipedia.org/wiki/Denatured_alcohol#Toxicity

I read the deadliness is kept secret (at least in Germany) since they want to avoid using it as suicide pills.

NAC is antidote. Not sure about the oral, but IV is for sure.

My relative who worked in a pediatric ER goes so far as to not allow Acetaminophen in the house.

It also killed Rory Gallagher, a famous guitarist

> accidentally took too much Tylenol for pain relief and suffered liver damage

For non-USians, Tylenol is a brand of paracetamol. The recommended maximum daily dose for an adult is three to four grams. Paracetamol toxicity is the foremost cause of acute liver failure in the Western world.

Also known as crocin.

I find it highly confusing how Americans seem to always reference branded medication. In the UK people generally take generic Ibuprofen (an NSAI) or Paracetamol at a standard does e.g. 500mg for paracetamol. Over time this seems way less confusing. There are quite a few branded versions but once you have an idea of the component parts it seems far less confusing to understand what you are taking.

The BNF provides some accessible guides to all pharmaceutical drugs:

https://bnf.nice.org.uk/drug/ibuprofen.html

https://bnf.nice.org.uk/drug/paracetamol.html

I don't mean to be insensitive RIP to what sounds like an awesome guy

I don't think it's that uncommon, plenty of people would say 'Nurofen' in the UK as well.

They might, but I think this is particularly common in the US due to the mandated branded medication in many healthcare scenarios even for drugs with lapsed patents. I think most younger, educated people in the UK would refer to them by the generic names.

I share this sentiment. Not knowing that "Tylenol" is Paracetamol I assumed it had to be some heavy, special, US-only painkiller, like those opioids which killed so many.

I have a box of this in my drawer - it's 20 pills totalling 10g - that's enough to damage a healthy liver if taken in the span of 24h.

I can't imagine the pain this man must have been going through to do this and mind you, I had kidney stones.

Not sure what he took...

Some versions of Tylenol have codeine in them as well. I got some stronger ones (Tylenol 3) after oral surgery and I had a few pills left and when a few months later my back was acting up and I was eyeing those pills I immediately flushed them down the toilet because I don't want to get addicted to that shit.

See https://en.wikipedia.org/wiki/Codeine/paracetamol here.

Please don't flush drugs down the toilet! If they are on the flush list (https://www.fda.gov/drugs/disposal-unused-medicines-what-you...) that may be ok, but in general bring them to a drug take back site. (Of course, when you are really at risk of addiction, there might be no choice...)

Off topic:

Did you identify the problem? Was it gout?

It seems awfully silly for a random internet stranger to diagnose your issue from "excruciating foot pain that came out of nowhere" but...

I had basically that off and on again for seven years before it was correctly diagnosed and treated. (As a healthy, active, relatively young person, gout wasn't suspected, but eventually an MRI gave a clue, and blood tests confirmed it.)

I got an X-Ray and it showed nothing. The doctor basically thought I was there to score narcotics but he wasn't going to get me any (I wasn't looking for them either but was told to eat Turmeric pills believe it or not - I did and don't have any way to know if it helped.)

Does gout come and go - I have not had trouble since then. If it returns I will be sure to do a blood test - and I really appreciate you asking. I am always for problem solving with or without strangers help :)

Yes it comes and goes.

In my case, the initial pain was relatively sudden, throbbing, enough to keep me awake at night. I also got an x-ray which doesn't tend to indicate gout, but did show some mobility issues (hallux limitus/rigidus) which were treated with increasingly expensive orthotic inserts.... and it went away after the initial issue for five years. Then it came back, new custom inserts (and some naproxen), went away for another twenty months. When it came back, it kind of stuck around, not the full on pain, but a dull aching that just wouldn't quit, thus the more thorough investigation.

In my case, I think the causes were a combination of gout triggers - not enough hydration, alcohol intake, high protein diets, etc.

I drink plenty of water - rarely drink alcohol but diet on the other hand may not have been all that good in the past although now I am on a lean one and move around a lot - I will definitely check for gout if it happens again. Thanks for bringing this up - it was bugging me on and off that I had something happen that I don't know the root cause for!

You might be interested in this NY Times article from last month. The comment thread also seems useful, with contributors talking about their own experiences. I was surprised to see fructose fingered as a chief suspect, mainly because of modern consumption of high-fructose corn syrup in many foods:

https://news.ycombinator.com/item?id=25102116

"Does gout come and go..."

Yes it does!! I want to shout here very loudly!

(I guess we're off topic now, but please please please don't do what I did and ignore it.)

Me, age 29, I've mentioned before that I'm a lifelong medium endurance cyclist (4-8hrs, 75-120miles): started to get foot pain. Went to the doc (Stanford Hospital GP), doc says you have gout, here's the pills you will take for the rest of your life. Me: nah, I'm healthy, I'll eat better. I was already eating better. Long story short, moved to a rural area, and had probably 30 attacks over 20 years, and none of the 5 (or was it 8?) docs diagnosed it correctly, or prescribed the pills, which are allopurinol. Take the pills. As you might imagine from my preferred exercise I have a very high tolerance for pain. Or did. I am not suicidal, but there have been several two week stretches where I became quite understanding about how people could be made suicidal from chronic pain.

Gout is not necessarily a virtue test. Take the pills. And you don't want advil/tylenol, you want indomethecin for the pain. For the last 5 years I take a half dose everyday and I've not had a single disabling attack, hallelujah. My joints still hate low pressure weather systems though.

Well, turmeric is good for you and anti-inflammatory, so it can't hurt. You could just eat a lot of curry though.

> it can't hurt

If taken in large enough doses to have a therapeutic effect it absolutely can have side effects, some not dissimilar from over the counter analgesics.

As someone in their mid-40s I can attest that random pains seemingly caused by nothing are part of the journey of life.

A few days ago I got out of bed and couldn't straighten my leg without insane knee pain. It lasted about a day and now it's absolutely fine. Yesterday I was vacuuming and my ankle just starts hurting like crazy. Fine in about 15 minutes. The other day I was bending over the sink washing dishes and my left shoulder blade gave me 7/10 pain. Seemed to be caused by an aggravated neck extensor but IDK.

Getting old sucks but I suppose it beats the alternative.

For me (also mid 40s) things got better after I diagnosed with Vitamin D3 deficiency - unrelated to the foot pain I had somewhat similar problems - vacuuming would blow my back out, game of tennis similar thing with shoulders. It got much better over the years and I like to think becoming D3 sufficient was part of it.

I had a year or two of chronic lower back pain and thought it was just the price of getting older (also mid 40s) and living a largely sedentary life. Then I started taking a Vitamin D supplement for a totally unrelated reason (mood, basically) and my back pain disappeared! I was extremely surprised (and happy!).

Fellow gout person here. I was finally prescribed allopurinol but I am not sure I want to take it long term due to the chance that it could cause liver and kidney damage but I need to do more research.

Fortunately gout can be controlled fairly well with diet but in the midst of a flare up, it is excruciating.

It’s called Paracetamol in the UK. We can only buy small packs of it (16 tablets or so) to try and prevent things like this. It’s very very rare to see Paracetamol issues in the UK news.

A great man, a crying shame.

Yes, that is one of the things I was amazed with when I moved from Australia to the USA. You can buy Acetaminophen over here in America in jumbo size 500 or even 1000 tablet containers over the counter - that's a lot of a pretty powerful drug.

10 tablets OTC is exactly same as 1000 tablets OTC.

Not really, you are not going to be able to walk out of a pharmacy with 100 boxes of paracetamol filling half a shopping trolley in the UK.

Not to mention pressing 100 pills out of their strips is a lot more work than taking a fistful out of a jar.

Why would you ever take a fistful of tylenol out of a jar?

Because you're getting yourself killed on tylenol. Who knows why people do that but it happens and putting it in strips adds another barrier to it.

Most shops limit you to two packs at a time as well.

Tylenol is deadly, the difference in the dosing between Children's Tylenol and Infants Tylenol has also unfortunately killed many babies - Acetaminophen is a very powerful drug. The FDA failed to fix it for more than 15 years during which many children died of Tylenol overdoses.

https://www.propublica.org/article/tylenol-mcneil-fda-kids-d...

It’s bizarre that in the USA they didn’t label infant Tylenol dosage. It’s labelled in other countries. We used infant Tylenol whenever our baby had a fever or otherwise was fighting off a cold. The dose size for children’s Tylenol goes way up (5ml). You'd think something was up when the syringes they give you for the infant type are max 2 ml.

One of my classmates died of Tylenol overdose when I was younger, so this lesson was imparted upon me rather quickly. She wasn't that close to me personally, but still, its a lesson I won't forget.

In that case, she got into a car accident and started taking Tylenol for some chronic pain related to the accident. A few months later, she was dead.

I...was in a car accident last Tuesday and been taking Tylenol like crazy. They refused to give me any prescriptions because I didn't have broken bones, despite the impact going 84 mph to zero in subsecond.

Thank you!

Do you know what's a good alternative to Tylenol? My chest and shoulder are hurting like hell.

Was it just the ED that refused you? Would be wise to go speak with your primary care provider and get their input, if you don’t have one it’s time to get one (if nothing else having one physician who has a complete history on you is a huge benefit).

The cop gave me a ride to the ED/ER after the accident, and the dr literally said "your x-ray is fine, take Tylenol or Ibuprofen" and just opened the door and left! Didn't talk to him more than two minutes total before and after the x-ray. They charged me 1,008 USD for that! The X-Ray itself was a separate charge by Radia and was just twenty bucks!

The nurse said the pain should improve within a week, but its been so already and I am still in pain even when I breath or move my arm up.

I'll tough it up for another week before seeing a Dr. I can handle the pain (had double kidney stones, one in each kidney before).

Ah, also, FYI for folks in the US: Do not reject Personal Injury Protection. The insurance agent told me my primary insurance will cover me, but then the hospital and my lawyer said that's false and insurance companies reject to pay hospital bills for auto-accidents. Later, they said they'll try to get a formal denial from my auto-insurance first and then try and see if my primary insurance will pay for it.

ER docs have, I think, been trained or conditioned to resist giving pain meds to people. I broke my foot about 6 years ago - badly. Lisfranc fracture, which is most common in football players (and is a career ending injury typically). I went to the ER in blinding pain, quite nearly passed out from that pain in the waiting room. They gave me a morphine injection, which helped a great deal while they did X rays. The doctor (mis-)diagnosed me with a severe sprain and tried to send me home without meds. I asked for some, and was reluctantly given a prescription for Tylenol w/codeine. I've heard similar stories from other people.

As a contrast, any time I've had even the most simple dental or other procedure, the doctors give me a prescription for pain meds without me asking for them (and in many cases not really needing them). So this seems to be specific to ER docs. I suspect it's a reaction to having to deal with people who are drug-seeking, but I don't really know for sure.

When I had my double kidney stones I only took a single Hydromorphone pill, and it was useless anyway for the pain, and didn't get me high either. Only psychoactive effect it had on me, was making it impossible to enjoy music for the rest of the day. I know the pill caused it, because the same thing happened at another time.

Never take tylenol "like crazy", the max dose of acetominophen is 4000g per day, but better to stick to 3000 if taking for more than a few days.

In the UK you can get cocodamol (paracetamol and codeine) over the counter for lower dosages, but pretty sure that's prescription only in the US, and more likely to lead to dependence.

I guess you rather meant 4000 miligrams :)

Yes - it was late at night and I forgot the m :)

> 4000g

That's a very unfortunate typo.

One I hope most people would recognize, thankfully. Taking 4 kilos of acetaminophen is something only a suicidal individual would do.

Careful: codeine is a very powerful (and addictive) drug. Many people have died of codeine overdose.

Is that why so many people in African countries are addicted to cough syrup?

Ultimately, that's a "talk to a doctor" kind of question.

My understanding is that if you stay below the warning labels, Tylenol is safe. But if you need doses high enough that you start bumping up against the recommended dose, DEFINITELY talk to your doctor about long-term use and possible kidney / liver damage. They may know of a safer solution (possibly an opioid: which has risks of addiction but... its the doctor's job to weigh the risks / rewards and your various options. Figuring out the right medicine probably requires a decent interview with you).

Getting addicted to an opioid might be "lower overall risk" than dying to kidney failure. Its bad options all around, but that's why we have doctors to help navigate your options.

-------

Good luck. I've never experienced chronic pain myself. I just know that being in that state means that you're probably not thinking through all your options 100% (just focusing on the pain-relief side of things). Which is why its important to get consultation from a doctor.

I know the urgent care facility in my neighborhood does primary care. Search around for urgent care facilities, they accept walk-in appointments. Ideally, you'd talk to a primary-care physician who has your medical history... but not everyone stays up-to-date with their doctor. (I certainly don't, and instead rely upon the urgent care walk-in appointments)

No broken bones probably means strained tendons / muscles and a (badly) bruised chest. Both are known to hurt a lot and for days if not weeks. Pain is a good thing in that it reminds you to rest.

If the doc already declined stronger painkillers, it's probably not without reason. I dont get why you would suggest opioids being the less evil in this case. I once got 60 pills of codein for a torn off toe nail while visiting over in TX. Needed maybe 2 of them.

Marijuana. Take as much as you want

You mean CBD, probably.

Yea, if that works for you, but in my experience marijuana helps relieve pain, CBD didn't really do anything for me.

It depends on the root cause of the pain; for inflammation and swelling that result from soft tissue injuries, I prefer diclofenac, although you need to be careful not to take it with an empty stomach, or mix with ibuprofen.

I would say, though, that this is something to talk through with your GP or a pain relief specialist.

Ibuprofen is more effective and less dangerous, though it has other side effects. So, don't take anything like crazy.

You might ask your doctor if the Voltaren (Diclofenac) cream, now available OTC, is an option.

As other said, really talk to your doctor, not just as the generic advice but also because there are many other options that can replace/complete/work better than Tylenol.

For instance there are Codein (an opioid) laced versions that are more efficient at lower doses (with other obvious aspects to watch for), or better identifying the source of pain can help target it more precisely (e.g. direct application gels).

There can be other mon drug related actions that help, if your doctor doesn’t give a shit finding another one would be your safest option IMO.

Holy shit. That's insane. People don't realize how terrible it is to die from tylenol induced liver damage. That's often considered one of the worst ways to commit suicide. You're in an incredible amount of pain for a long time.

> That's often considered one of the worst ways to commit suicide.

I came close to seeing that first-hand some years ago: My (widowed) dad suffered a long, agonizing death from a form of leukemia. I was with him, at his house, for his final week, with a hospice nurse checking in periodically. He refused morphine and instead took a fair amount of acetaminophen; for calories, he drank a lot of beer and V-8 juice mixed together. I warned him about the danger of mixing alcohol and acetaminophen; he immediately perked up, thinking that would be a way for him to end things. He was disappointed when I explained that it wouldn't be a quick death: he'd just wreck his liver and be in even more agony. (He died a few hours later.)

Sorry for your loss.

I only learned about it because a local soap opera[1] made it a plot point in the early/mid 90s.

[1] Shortland Street

> You're in an incredible amount of pain for a long time.

Just take some tylenol.

This is scary to read, as I've been there. All my friends know not to give me Tylenol. I think on two occasions now I had slight pain and took maybe two or three extra strength Tylenol, and was found on the floor shivering, sweating, waiting for death. This wasn't even an OD, this was recommended dosage. I don't think I'll ever take Tylenol again, I'll deal with the pain. This felt like my kidneys were on fire and not so much liver, so what do I know.

Based on having that reaction, I wouldn't suggest you take Tylenol again.

For others, the recommended dose of extra strength Tylenol is two 500mg tablets; but if you only have a minor pain, you don't need to take two tablets, or you could take regular strength (325mg), again the recommendation is two tablets, but you can take less. More than 1g in one dose, or 3g over a day is extremely inadvisable. Acetaminophen (paracetamol) is toxic at a small multiple of the recommended dose; prescription strength acetominophen products add other active ingredients, they don't add more acetaminophen; as opposed to ibuprofen where prescription strength is just more ibuprofen. I'm not a doctor, this isn't medical advice, etc.

Why would some think excessive Tylenol would be preferable over narcotic pain meds How much Tylenol would a person have to consume over a two month period to permanently damage their liver This is bizarre.

Just consuming more than 4g on one day may be enough to start the liver failure, especially if using alcohol or other drugs.

Protip: have some N acetyl cysteine handy. It's freely available on amazon, and it protects your liver from acetaminophen abuse (and helps rebound faster the next day after a night of heavy drinking, but the FDA absolutely hates when people mention that :-)

EDIT: replying here as HN things I'm "posting too fast"

Whenever in doubt, by default, you take it due to its extremely good tolerance.

There are no bad side effects at usual doses, even after 50+ years on the market (well, at very large doses, vomiting, which I think is good in case of acetaminophen or alcohol poisoning)

https://en.wikipedia.org/wiki/Acetylcysteine

Don't let the FDA make it illegal:

https://www.sgtreport.com/2020/08/use-n-acetylcysteine-the-f...

https://fda.news/2020-08-21-fda-trying-make-n-acetylcysteine...

If you have this on hand, how do you know if and when to administer?

Not a doctor. I just take it when I feel shitty. I figure there is a correlation between not feeling great and oxidative stress in my whole system.

Many stronger drugs have acetaminophen in them. I've tried oxycontin and had very little benefit. People should know for themselves what works for their pain but never underestimate the damage drugs can do, even if they're over the counter.

> How much Tylenol would a person have to consume over a two month period to permanently damage their liver

Liver damage can occur after a single incident. People have died from single time overdoses of paracetamol. There is a quick fix in an ER of giving NAC which can help eliminate most of the damage, but there is a small window(a day or two) where it is effective.

I have a load of NAC on hand. Would it be a good idea to take it whenever I take Tylenol? I can't imagine a pharma pathway that would result in it attenuating the painkiller effect. Just mop up the oxidative damage.

Read the label. Switch to Aspirin, either completely or half/half. If possible, try fixing the underlying problem, not the pain.

Not a doctor and I wouldn't listen to medical advice from HN, but you can find a lot on this:

>Therefore, it may be beneficial to administer APAP(Tylenol) in combination with NAC routinely to reduce rates of liver failure and death. Because NAC's main role is to reduce the accumulation of APAP's toxic metabolites, the concomitant administration of NAC should have no impact on the efficacy of APAP as an antipyretic and analgesic.

From: https://clinicaltrials.gov/ct2/show/NCT01137591 .

I've seen probably a dozen people in my high school class die from their narcotic pain meds originally prescribed to them. I only took a quarter of what was prescribed after surgery from shattering my leg, and yet weening off was worse than the pain from the injury.

I don't blame him for the choices he made, having been there.

Unless your local pharmacist is a serial killer, this stretches credulity.

How?

A dozen deaths in one HS graduating class? Really? That would raise suspicions on 'Dexter.'

You're referencing media I don't know, I don't understand why you don't think the scope of the opioid crisis that has claimed thousands could involve the deaths of 12 people with 1 thing in common. Pill mill pharmacies are a thing, and some of those pharmacists have been charged with crimes.

He means a year in HS, not a single classroom. That's a few hundred people.

And the way pharmacies were handing out opioids it's quite possible. Wasn't called a crisis for nothing.

Yeah, ~1200 person class.

So your class had a 1% death rate due to prescription opioids. Why do you suppose it was so far out of proportion to the general population? drugabuse.gov says prescription opioids accounted for around 15,000 deaths in 2017 [1], so 12 in a single high school graduating class is either a massive unexplained spike in the data, or something you made up.

1: https://www.drugabuse.gov/drug-topics/trends-statistics/over...

I'm not who you're replying to, but don't you think that given we know pill mills exist, it's likely the data is actually highly location specific? I.E., a city with one is more likely to have lots of ODs compared to the national average? Have you taken a statistic course? At this point I'm not sure what you're objecting to anymore.

A 1% death rate due to prescription opioids in a high-school age population sounds utterly unprecedented.

If true, it's interesting, and genuinely disturbing. I'd like to learn more about how something like that can happen at that scale.

If not true, it belongs on some other site where people don't care about what's true and not true.

Depends on what "die from their narcotic pain meds" means, and how big the high school class is, how long they've been out of school, and where their school is located.

Oxycotin pill mills.

I mean, I'd argue they're serial killers, but what they're doing is legal.

In my case I went to the doctor only after trying to bear it for as long as I can - they did an x-ray and said there's nothing wrong with your foot and you'll just have to ride it for some days. Heck the doctor asked me to eat Turmeric pills - not even kidding. He made sure I wasn't getting a narcotic - and I wasn't looking for it because I am really afraid of side effects. (My wife is the same way - brave woman went without touching the narcotic meds after tooth removal.)

That pretty much leaves you with OTC pain meds - I know in these cases probably narcotics of the right kind in restricted doses sound much better but I am just truly afraid of side effects because of what we saw earlier in life.

I've had pretty much the same experience (minus the recommendation for Turmeric).

Once I was lucky enough to get a steroid prescribed and it worked wonders compared to a dose of Ibuprofen every 4 to 6 hours.

I know someone who ended up hospitalized from accidentally taking two over-the-counter meds that both contained Tylenol. It just doesn't take that much to cause damage.

Honestly, this one does surprise me. American doctors give out opioids like nobody's business. They give you narcotic painkillers for post-tooth-extraction pain! That's ridiculous! The problem, I think, is that many people are foolish enough to "return their unused prescription". I never do that. I make sure to retain unused drugs to their true expiry.

It must have been really quite painful. Still, I'd strongly recommend keeping drugs of all manner handy if you've got good self-control around them. They have high utility.

Mine gave me high strength ibuprofen and percocet after wisdom tooth removal. I didn't take either because it didn't hurt, but they called me up after to make me take the ibuprofen - apparently the anti-inflammatory effect is needed for healing or something.

I took the ibuprofen too. I didn't get mine done in America so sadly no emergency Percocet in my cabinet.

The DEA has cracked down tremendously on healthcare providers that over-prescribe opioids, though. Granted I'm sure there are many who still prescribe them like crazy, but it seems like active measures are being taken to curb it.

That's unfortunate. I've always wanted backup in case I really need it. Pity that we policy society by its least capable but I understand why it's necessary.

It's quite common. At least in Europe, available sizes of Paracetamol were severely limited not too long ago because it was the leading cause of overdose deaths.

Individual risk isn't exactly high, but OTC painkillers are ubiquitous.

Both accidents and suicide attempts are/were frequent. It's a rather terrible way to die, IIRC, with excruciating pain and entirely too much time to regret the decision/accident.

Tylenol is surprisingly easy to overdose on and is well known to cause liver damage. This is especially true if you take extra strength tylenol. It is recommended to stay below 3,000 mg of tylenol within 24 hours, which is only 6 extra strength pills. If you take a bit extra and get over 4,000 mg per day for multiple days, you can get major issues. There just is not much margin for error with tylenol.

I think people often get confused because you can typically take a bunch of ibuprofen pills for pain and there are rarely serious side effects. But ibuprofen and tylenol are much different in this regard, despite the fact that both relieve pain and both can be easily bought in a drug store.

> This is especially true if you take extra strength tylenol. It is recommended to stay below 3,000 mg of tylenol within 24 hours, which is only 6 extra strength pills. If you take a bit extra and get over 4,000 mg per day for multiple days, you can get major issues. There just is not much margin for error with tylenol.

Huh? To actually think that taking 6 extra strength pills in 24 hours isn't enough margin of error? I mean maybe if the person is completely clueless and doesn't read the medicine instructions.

Honestly, if you're in that much pain that you're gobbling up 6-8 extra strength pills per day, every day, you should be in the hospital with an IV hooked up, or addressing the chronic pain issue that's causing it. Or have the doc prescribe you something way stronger.

I don't know about other people, but for me paracetamol does very little, so if I had even moderate pain I could see why I would be tempted to take too much.

On the other hand, UK has OTC ibuprofen+codeine which can fix essentially anything.

Right.

OTC painkillers are usually not meant for moderate+ pain, at least the stuff available in USA.

They're meant for taking you from 3/10 to 1/10. I know most people don't think about it in-depth, but surely we can expect at least some basic logic from them?

Like don't swallow pill #6 if the first 5 extra strength pills did nothing.

The directions on extra strength tylenol say:

-take 2 caplets every 6 hours while symptoms last. -do not take more than 6 caplets in 24 hours, unless directed by a doctor.

It's not too crazy that someone in pain or feverish could think "maybe if I just take an extra pill or two I'll feel better and it will be totally safe..."

Tylenol is over-the-counter, while you need a doctor to prescribe narcotics.

As such, Tylenol overdose is more common. The labels are very clear about how much to take, but when you're in chronic pain, you may not be thinking much about the warning stickers or labels.

Tylenol is really not to be abused. Much better to go heavy with Ibuprofen and remember the old-time drugs like aspirin as well as new ones like naproxen.

But really a doctor/nurse is critical if the pain is going on for more than a day or two.

> Much better to go heavy with Ibuprofen

Do you know that Ibuprofen can cause morphological changes in the testes? I wouldn't call that much better...

It's a lot easier to live without testicles than without a liver.

NSAIDs (such as ibuprofen) are rough on the kidneys. I didn't know about GP's point, but of course that fits, anatomically.

Yet many people take paracetamol without issue - you just need to read what the max dose you can take is (2x500g tables at least 4 hours apart and no more than 4 times per day) and not for more than a few days at a time.

The bigger danger is people mixing it with other cold and flu medication that ALSO contains paracetamol.

Paracetamol/acetaminophen has an extremely small therapeutic range for an over-the-counter drug. Yes, if you follow the dosing instructions (and are aware of all sources of the drug you're taking and also aren't drinking alcohol or something simultaneously) you'll be fine, but if you discovered this drug today the odds that it would be approved for over-the-counter use are basically zero.

Alternating drugs can be pretty effective. Tylenol, Ibuprofen, Tylenol.

The two don't interact with each other which helps to keep the pain (or fever) relief going strong without ODing on either.

But yeah, be careful either way.

Many medical professionals recommend against alternating, not because it is unsafe but because the mental overhead and differing schedules depending on dose can lead to mistakes and lead to accidental overdose if you aren’t paying attention or writing it down.

Also, make sure you are only taking one NSAID (acetylsalicylic acid/asprin, ibuprofen/Advil/Motrin, naproxen sodium/Aleve) if you are alternating painkillers - if you take excedrin/generic “migraine” formula you are already getting a dose of asprin and should not take anything else with it.

All very good points.

You should absolutely read the labels of your pain medications and know what's in them. If you aren't sure about interactions, Don't screw around. Just take one and follow the directions.

Be particularly aware of cold medicines as they very commonly like to do the mixing for you.

And there was me thinking 'Tylenol' was ibuprofen.

I think it's so weird (different English speaking) countries having different names for drugs, you'd think it would be something worth standardising. Well, acetaminophen is the standard/medico name I believe (paracetamol to Britons), but why don't we just all use that? Weird.

While I'm at it, Advil = ibuprofen. The latter being both the common UK and 'standard' name I think.

Brand name vs generic basically.

A full name for the compound is: para-acetylaminophenol

Now you can trace where all the names come from :)

It's branding, it's a marketing thing.. Which has been quiet effective seeing how many people say Advil and Tylenol on here.

Do other brands of 'Tylenol' and 'Advil' even exist inside the US? It amazes me because branded medicines are so much more expensive as well. Like 5 to 10 times more

Yeah, it's just weird. In the UK paracetamol isn't a brand name, it's the generic term for a commodity product, 'nobody' cares who's name is on their paracetamol, I usually buy it with groceries if I'm low, so it's whichever supermarket brand.

The only (non-supermarket/chemist) brands I could name even would be e.g. Lemsip, where the paracetamol isn't the main constituent (it's a lemon flavoured sore throat/cold soothing drink, if you don't have it there) but an additive in some SKUs (also caffeine).

So you can get generic brands of 'tylenol'? People just trust/think better of Tylenol?

Reading this whole thread, it almost seems like an opioid or an opioid combined with naloxone (suboxone?) would be rather safer than tylenol/acetaminophen. At least with opioids, the risk of overdose is far more widely understood, and a remedy to overdoses (naloxone) exists, in case it happens. There is the downside of its addictiveness, but in particularly severe cases of patients suffering from really bad pain, it sounds like controlled, limited doses of opioid-based pain killers might be safer? I'm not a doctor, I'm just wondering.

I heard that if Tylenol was released today as a new drug, the FDA would not approve it, which is kind of scary to think that it's on shelves now.

What's the alternative? Ibuprofen? Aspirin?

Hmm, acetaminophen/paracetamol is listed here next to aspirin, ibuprofen and opioids are also listed there. I don't think it would not be approved at all, maybe not for over the counter sale. Here in Germany you get it only in pharmacies. No prescription is needed for buying up to 10g of active substance per visit.

https://en.m.wikipedia.org/wiki/WHO_Model_List_of_Essential_...

I have gout and when it flares up it is the worst. I am in serious foot pain for anywhere from a week to a month or longer. Currently I'm dealing with a buildup of gouty tophi on my heel that has been there for a few years and finally surfacing and causing real issues. I thought it was just a callous from walking with flip flops for too long or something, but nope, just more gout coming around to ruin my days.

It is very depressing that, on top of the pain, I feel like I'm constantly making excuses why I can't do things with my family. Often times I will "power through it" and just make things worse.

Nowadays I am quick to get on my crutches and keep my foot elevated at any hint of a flare up.

I did not know of Eric but can certainly understand taking too much Tylenol for foot pain.

I'm not sure if it's true, but I recall reading that Tylenol is the most commonly overdosed and misused drug. Combined with alcohol it'll destroy your liver, even in low dosages.

I smashed my middle toe into a table while play-chasing my dog around the house. I was instantly in enormous pain, but able to hobble around.

Later that night, I was in so much pain that I literally could not walk at all. I was laughing and crying at the same time, it was ridiculous that I was in so much pain over a TOE. Not even the big toe at that. I had to crawl to the bathroom to pee. Luckily it just took another day and I could hobble on it again.

Ugh, it is shocking how many people don't seem to realize what acetaminophen does to the liver. I had buddies who used to pound tylenol after a long night of drinking to try to help a hangover in college. I'm actually kind of shocked this didn't happen to any of them.

PSA: don't drink and take tylenol, please. The warnings on the bottle aren't a joke.

As someone who takes paracetamol instead of NSAIDs (ibuprofen, aspirin) because of increased sensitivity, this scares me. I do have a hard cut-off of three 500mg tablets in 24 hours, and I never take more than 500mg in a 6 hour period.

I should ask my doctor for a non-NSAID alternative painkiller.

I heard somewhere that under 40 (or was it 45?), most people die of suicide or trauma. After that, people can die of pretty much anything. Just goes to show...

Tylenol overdose is too common. I doubt the medicine would be legal today if someone tried to release it now.

Doubtful. He was probably addicted to vicodin or some other opiate that is mixed with tylenol

The lack of easy access to strong painkillers kills people, driven to extreme by the madness of pain.

Yet we only talk about the evil of drugs, and the opioids epidemic.

What is the opioid epidemic?

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