Tylenol overdose and the public's ignorance.

[GardenDove]

I had a Tylenol overdose pt yesterday, suicide attempt. In my opinion, the public is grossly undereducated about Tylenol and it's effects on the body. My pt had people rallying around him all day yesterday, got the clearance from mental health to be discharged, and was ready to go home! Unfortunately, his Hepatic panel was sky high, he still had an Aceteminphen level of 20 over 40 hrs post ingestion, still needing a N-acetylcysteine drip, and he might very well end up on a transplant list.

I tried to explain to him that Tylenol doesn't kill you right away, but can cause liver damage. Finally, the doc came in and laid it all out for the pt.

In my opinion, a public service campaign on a national level is needed regarding the dangers of Tylenol. This is needed for chronic pain sufferers, who don't understand that Tylenol is an ingredient in many products, and that it is toxic if over used. And it's needed for everyone else who might used Tylenol overdose as a cry for help and attention.

From my observation of my pt, he definately was basking in the attention, both from the girlfriend who had just dumped him, and his friends who had rallyed to his side. Meanwhile, he may end up dying while awaiting a liver transplant.

I think the public needs more information about Tylenol.

[mama_d, BSN, RN]

I don't even have Tylenol in the house. We use ibubrofen for run of the mill pain mgmt. Our 12 year old gets migraines, and takes 400 mg of ibuprofen for mgmt of them...he is already aware of his dosage and the various names it goes by, as well as the fact that Aleve and all of the names it goes by are in the same class.

There is a real lack of education on this subject, I completely agree. The Tylenol left the house after I discovered that hubby was combining Ultracet, Vicodin, and Tylenol for pain issues while dealing with a tooth abcess. After living with a nurse for ten years he still didn't know that all of them had Tylenol in them, although he was aware of the possible effects of a Tylenol OD from previous discussions. His question as a lay-person was "Why isn't it clear that all these things have Tylenol in them?" I could only agree with him that it should be clearer.

How is it that all the commercials for prescription meds have to have that long list of possible adverse reactions, but no one knows what Tylenol OD can do?

[Hygiene Queen]

You're right, Dove. I've lost track of how many young girls took a handful of Tylenol because they got into a fight with BF/Mom/Dad/whoever and decided to scare them. No one is more surprised than the pt when she ends up in ICU.

The public just doesn't understand that just because a script isn't necessary, the med is not completely harmless.

Tylenol seems to be the drug of "choice" for teenagers (esp. girls) looking, not truly for death, but attention.

It is so sad and frustrating.

I had a pt who had already had a liver transplant years ago after a Tylenol OD... and she went and did it again.

Yep, good luck getting another liver...

[elkpark]

Tylenol seems to be the drug of "choice" for teenagers (esp. girls) looking, not truly for death, but attention.

It is so sad and frustrating.

Exactly -- and they intentionally choose acetominophen precisely because they believe it's safe and they're not really taking a risk (child/adolescent psych is my field). Drives me crazy.

[Jonathank]

Not only is there the very common public misconception (about OTC meds in general) that "if it's OTC, it must be safe," but McNeill (the company that makes brand-name Tylenol) has run all those TV commercials and magazine ads for many years informing everyone of how safe Tylenol is ...

Think of all the disclaimers that have to be included for all the most remote possible side effects for prescription meds, and yet this OTC med gets to advertise without even mentioning that it is hepatotoxic. Thank the pharmaceutical lobby for this lack of oversight.

[KJStarling]

I agree it's a serious drug and the public percieves it as "safe" because it's OTC. I worked with a lovely woman (waitressing) who had chronic back pain, and killed her liver by taking "extra" tylenol over a few months. She didn't get a transplant in time and died a painful death. It was so sad and many people were surprised and angry because "it was just tylenol..."

[LPNnowRN]

It's hard to explain total milligrams per day to a patient when you're trying to educate someone on discharge--they usually take Tylenol at home and are going home with Vicodin--I've had patients tell me it's "too confusing" and just promise never to take anything OTC with the Rx. You just pray they actually don't! I go into the liver transplant spiel too...nothing like scaring your patient to get results, LOL.

[klone, MSN, RN]

We don't keep Tylenol in the house. We use Motrin (for young children and adults alike) for pain management.

A friend of a friend died of an accidental Tylenol overdose - she was fighting a horrible migraine over a 4-5 day period, and she was just not keeping track of how many she had taken.

I remember in nursing school when I did a rotation in the ICU, a 14yo girl who was in there for suicide attempt. Except that she admitted she was just trying to get attention and didn't realize Tylenol can actually KILL you.

[Not_A_Hat_Person, RN]

When I was in pharmacology, my teacher said that if Tylenol Had to go through the FDA as a new med today it would NEVER pass.

Neither would aspirin. Any drug can kill if you take too much of it. Should aspirin be prescription only?

Benadryl causes serious drowsiness. Pilots who have taken Benadryl aren't allowed to fly. In many states, driving after taking Benadryl can lead to a DUI charge. Should Benadryl be prescription only?

[CCL RN, RN]

Neither would aspirin. Any drug can kill if you take too much of it. Should aspirin be prescription only?

Benadryl causes serious drowsiness. Pilots who have taken Benadryl aren't allowed to fly. In many states, driving after taking Benadryl can lead to a DUI charge. Should Benadryl be prescription only?

That's stilly. People can OD on water. That's not quite what we are talking about here. Not by a long shot...

Acetaminophen overdose is the leading cause of liver failure in the US and the United Kingdom and the leading cause of calls to the Poison Control Centers across the US. It is estimated that acetaminophen poisoning calls exceed 100,000 per year. Studies indicate that acetaminophen overdose results in over 56,000 injuries, 2,500 hospitalizations, and an estimated 450 deaths per year.

http://www.lawyersandsettlements.com/case/tylenol.html

(1996 - NSAIDS) "Each year, use of NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) accounts for an estimated 7,600 deaths and 76,000 hospitalizations in the United States." (NSAIDs include aspirin, ibuprofen, naproxen, diclofenac, ketoprofen, and tiaprofenic acid.)

http://drugwarfacts.org/cms/?q=node/30

Hard to find real data on diphenhydramine on the fly. The Tylenol stuff is easy.

And everyone knows that diphenhydramine causes drowsiness. It's on the label. Is death and liver failure on the label of acetaminophen?

[MunoRN, RN]

"The Dose makes the Poison".

My dad, a retired toxicologist, would have wanted his favorite quote of all time included in this discussion.

Everything can be toxic given the amount, which is why we look at therapeutic range; or the ratio of how much of a drug it takes to provide therapeutic effect (ED50) vs how much will kill you (LD50). The traditional definition of LD50, or how much of a dose would be lethal for 50% of the population, is based on a single dose, not chronic use. Based on a single dose, tylenol has a fairly safe therapeutic index, even though if you consider repeated use the index narrows significantly.

The FDA regulates based on the traditional (single dose) definition, so it's hard to say if they would place the same restrictions on tylenol they do with with other drugs that have a narrow index such as warfarin, lithium, synthroid, etc, which is that a prescription is required and regular monitoring must be done. My dog is on a potentially hepatotoxic drug for arthritis, and even though it is a low dose I'm still required to have a liver panel done every 6 months. I don't think I've ever seen a patient who routinely takes tylenol containing meds that has their liver function followed routinely.

The FDA doesn't usually address issues with drugs once they've been approved, they may change their requirements for future drugs but rarely apply those requirements to drugs already on the market. Albuterol for instance wouldn't even qualify to apply for FDA approval much less earn approval if it were to apply today. But at least with the case of tylenol the FDA is planning on making some new requirements regarding labeling and allowed dosages when mixed with other drugs.

[~Mi Vida Loca~RN, ASN, RN]

Tylenol seems to be the drug of "choice" for teenagers (esp. girls) looking, not truly for death, but attention.

It is so sad and frustrating.

I had a pt who had already had a liver transplant years ago after a Tylenol OD... and she went and did it again.

Yep, good luck getting another liver...

I was a teen that od'd on Tylenol twice. It wasn't for attention, it was because I didn't know it wouldn't work. First time I did it with generic. I took like 40 and nothing happened. I never told anyone. A week later I tried again with name brand. I thought maybe that was why it didn't work. I took 50. An hour later I started throwing up and was fine. Never told anyone. Just assumed I couldn't even kill myself right. This was when i was 15. When i was 19 i was in a bad car accident and was given vicodin. Thought i would try my luck with that and took i think it was 28 of them, that didnt go over so well, i didnt tell anyone but it got out and i had to go to ED. My point, none of those times was for attention. I had no idea the Tylenol wouldn't work as I imagine a lot of people don't know either. But I am now thankful it didn't work, I think teen girls go the pill route more because you think you will go peacefully in your sleep with no pain. Women in general, They say that woman try to commit suicide twice as often as men but more men die from it because they go more violent or lethal routes. Woman are usually to scared to go that way. At least that's what I have learned. Not always true though, my grandma used a gun.

Later on in life I learned Tylenol is a long term killer. Got my liver checked and thankfully I was ok.

It wasnt until I was in nursing school that I found out just how bad Tylenol is. Huge misconception out there, know so many people that would take it before going out drinking to help keep the headache away. School opened up my eyes to a lot of things I had no idea about. Definitely needs to be a lot more knowledge out there regarding this stuff.

[~Mi Vida Loca~RN, ASN, RN]

Btw. Have seen quiet a few patients in clinicals in liver failure on vicodin. Our instructor told us to ask the doctor why once. She is a NP hospitalist. The doc didn't have an answer.