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.

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.

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.

Kind of like how they used to put methanol into alcohol during prohibition, knowing full well it would kill some people, in an effort to scare people away from alcohol.

Even if that's not the case, it does seem reckless to put so much acetaminophen into each individual pill. I'd be very curious what percentage of those deaths were from overdoses on Vicodin and Percocet.

Acetaminophen doesn't actually reduce swelling (although it does reduce fever). Ironically, it's mostly... a mood-altering drug. http://www.theatlantic.com/health/archive/2013/04/whats-tyle...

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.

I'd venture to guess that most acetaminophen/paracetamol users aren't popping Tylenol (etc.) every four hours for weeks at a time. But four Vicodin pills a day, taken over the course of a week or two -- not an unusual dosage for pain relief from major surgery or illness -- will concentrate an extremely large amount of acetaminophen in your system, because acetaminophen is eliminated fairly slowly from the body (and at great cost to the liver).

You're probably not going to kill yourself taking that much acetaminophen. I've done it a few times, and I'm still here. But you might do some serious, potentially irreversible damage to your liver. It's sort of like heavy metal poisoning: it takes a lot to get an acutely toxic dose, but a slowly toxic dose can accumulate over time.

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 .

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.

If you keep to the NHS guidelines you'll be fine (http://www.nhs.uk/Conditions/Painkillers-paracetamol/Pages/I...)

your issue is that you had an opiod mixed in. That is where the "huge risk" is. Both opiates (especially ones like codine that require the liver to work) and acetaminophen (paracetamol) hammer you liver, which is fine so long as you don't take the piss.

Co-codolmol (the UK equivalent of vicodin ) is still available over the counter with a 8/500mg is available without prescription here in the UK.

update

Reading the article its very hard to see what point they are trying to make. The evidence they offer to suggest that its unsafe is vague. Prolonged exposure is bad, and almost doubling the dose is doubly bad.

The basic rule of thumb here for any medicine is this: READ THE LEAFLET. DON'T MIX AND MATCH. TALK TO A DOCTOR.

Most medicine is toxic, and if you double the amount you take bad shit happens. If you OD on codine you stop breathing, why is it a surprise that if you OD

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.

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).

   "The 4 gram per day recommended dose is also the maximum safe dose, one that 
   must not be exceeded, an unusual situation for any drug, particularly an OTC 
   drug, one placing a large fraction of users close to a toxic dose in the 
   ordinary course of use," the report said.

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.

    You might want to rethink your position

As far as interactions, you're right, it does interact with other drugs and non-drugs (the fact that lots of other OTC medications contain acetaminophen is also troubling, but a different issue in my mind), but in my experience as a guy who has to take a lot of painkillers and who's married to a nurse who takes care of figuring out what's safe, acetaminophen is one of the less worrisome drugs to deal with. On re-reading, I pretty clearly chose a bad way of expressing myself with the word "lack"- I meant "fewer" rather than "none at all"- so sorry about that, but with the appropriate disclaimers about don't take my advice, etc., I stand by my statements as regards my own experience- acetaminophen is very safe and very convenient when you don't overdose. Unfortunately, as I have just learned, it's really easy to overdose, and that's really sad and a big problem.

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.

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

(Edit: Googling for "aspirin suicide", find it in top 20 list of suicide methods http://wantdeath.blogspot.de/2011/07/method-5-of-suicide-asp... )

Did you read the article? The whole point of it is that the dose of acetaminophen found in many pills in the US is dangerously close to the level at which liver damage occurs.

The same can't be said for other painkllers.

For me ibuprofen is a miracle. I get bad headaches from time to time that aspirin and acitominphen have negligible impact on. Ibuprofen knocks them out completely.

http://onlinelibrary.wiley.com/doi/10.1002/hep.20948/pdf

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

[2]http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aKQxd...

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

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

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

   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.

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.

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

> 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.

How would you distinguish them?

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

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