Conspircy theory question about Acetaminophen in opioids

[Dominus Atheos]

Thing I heard, want to know if it could be true. Paraphrased:

Drug warriors add acetaminophen to opioid pain medication in order to cause nausea/malaise when abused, but acetaminophen also causes liver damage which makes it easier to overdose on the stuff. But drug warriors don't care because it's all counted as opioid overdose so they can point to that and say "See? Opioids are dangerous and need to be banned!".

Pure opium isn't actually all that dangerous physically, just the shit that's added in order to punish people who use it.

Is it true that acetaminophen is added to Vicodin/etc primarily in order to make the side effects of over-use worse?

Do opioids cause liver damage?

What long term damage does pure opioid(opiate? Opium? I don't know what the singular of that word is) do physically?

Could liver damage make fatal opioid overdose easier?

Could liver damage make fatal acetaminophen overdose easier?

Do current statistics account for acetaminophen overdose separately from opioid overdose?

Would autopsies even mark deaths from the acetaminophen in Vicodin separately from deaths caused by the actual opioid?

Full discolsure: I don't take opioids and don't really have a dog in this fight, but I really don't like drug warriors and am fairly convinced that they lie a lot.

[Adam Reynolds]

Given that there are pure hydrocodone products like Hysingla, the short answer is no.

The list of possible side effects for this drug give an idea as to the potential problems with pure hydrocodone:

any type of breathing problem or lung disease;

a history of head injury, brain tumor, or seizures;

a history of drug abuse, alcohol addiction, or mental illness;

urination problems;

liver or kidney disease;

a heart rhythm disorder called long QT syndrome;

a blockage in your stomach or intestines;r

problems with your gallbladder, pancreas, or thyroid; or

if you use a sedative like Valium (diazepam, alprazolam, lorazepam, Ativan, Klonopin, Restoril, Tranxene, Versed, Xanax, and others).

[Broomstick]

Drug warriors add acetaminophen to opioid pain medication in order to cause nausea/malaise when abused, but acetaminophen also causes liver damage which makes it easier to overdose on the stuff. But drug warriors don't care because it's all counted as opioid overdose so they can point to that and say "See? Opioids are dangerous and need to be banned!".

Actually, it's the opiates that cause nausea, NOT acetaminophen! Many, if not most, first time users of large doses of opiates will experience nausea or even vomiting.

Acetaminophen doesn't "cause" liver damage at therapeutic doses in most people. Too much acetaminophen, i.e. "overdose", does cause liver damage. Acetaminophen + alcohol makes this more likely.

Pure opium isn't actually all that dangerous physically, just the shit that's added in order to punish people who use it.

This is true up to a point - pure opium (or opiates) at therapeutic doses is not very damaging (although overdoses can be fatal). In the case of FDA-approved medications NO, stuff is NOT added to opiate formulations to "punish" anyone.

Keep in mind that opiates mimic naturally occurring substances in the body called endorphins. They are very similar, and the same mechanism the body uses to break down/process the natural chemicals work equally well on the opiates.

Is it true that acetaminophen is added to Vicodin/etc primarily in order to make the side effects of over-use worse?

No, complete bullshit. Opiates and acetaminophen relieve pain by different mechanisms and by combining the two greater pain relief can be achieved by lower doses of each than if they were used singly.

My husband is currently undergoing treatment for cancer. His two main pain medications are pure morphine sulphate (extended release) and something called "norco", which is an opiate (hydrocodone) and acetaminophen. He consistently reports greater relief of acute pain with the combination, and will choose the combination over a higher dose of just the morphine. Mixing opiates and other pain relievers (like acetaminophen, ibuprofen, aspirin, etc.) is done to provide another option for pain relief that works better than just opiates at least some of the time. It's not done to punish people.

Do opioids cause liver damage?

No.

Slightly longer answer: because of the variability of human biology there probably are people for whom opiates cause or exacerbate liver problems, but liver problems in an opiate user are almost invariably combined with a combination pill (like norco) combining opiates with acetaminophen, and the damage is caused by the acetaminophen.

However, liver damage can alter how fast the body processes any drug, which can lead to significant problems regarding dosages and duration of effects. This can complicate medical treatment, and can lead to a greater chance of overdose because the drug isn't cleared as fast from a person's system as it normally would, leading to the drug building up in the system.

What long term damage does pure opioid(opiate? Opium? I don't know what the singular of that word is) do physically?

Constipation. And by that I mean slowing the digestive tract to the point that in extreme cases surgery may be required to remove impacted feces that have essentially solidified into a wad of cement. That's a rather extreme case, but it has happened. More typically is just nasty, nasty constipation where the person only shits once every week or two, with bloating, pain, etc.

Brain damage brought on by episodes of hypoxia due to high doses/over doses interfering with sufficient respiration.

Also, "opioid" is a category of drugs, like "antibiotic" or "NSAID". "Opiate" is generally the singular - "I am taken an opiate for this third degree burn I got saving kids from a flaming school bus". "Opiates" is plural: "Cancer pain sucks, they have me on two different opiates to deal with it."

Could liver damage make fatal opioid overdose easier?

As a general rule, liver damage makes any fatal drug overdose easier.

Could liver damage make fatal acetaminophen overdose easier?

Absolutely. No questions. Yes it does.

Do current statistics account for acetaminophen overdose separately from opioid overdose?

Yes.

Acetaminophen overdoses cause liver damage and in the US is the currently leading cause of sudden liver failure and liver transplants. Opiate overdose involves suppression of the respiratory system, leading to what is essentially suffocation (in some cases, opiate overdose can leading to vomiting, aspiration, and choking, where the victim essentially drowns in their own vomit). The two mechanisms of death are easily distinguished on autopsy even without performing a toxicology report.

Would autopsies even mark deaths from the acetaminophen in Vicodin separately from deaths caused by the actual opioid?

Yes, absolutely.

[Sea Skimmer]

This is some of the dumbest complete bullshit I ever saw on the internet, but with the president now in command of the troll armies and alternate reality legalized I figure I'll be saying that a lot in the near future.

The evil drug companies add acetaminophen to many opioid drugs because makes them more effective, with less side effects and in a manner which can't be replicated by just taking more opoids. In fact the only reason not to use a opioid mixed with such a drug or similar is if other medical problems contraindicate it. Otherwise pure morphine or whatever, its a terrible choice for anything in terms of effectiveness per dosage weight. The fact that people will more easily overdose and die from pure opoids, and be more likely to abuse them as a fact of reality, is just a side issue in reality.

[Terralthra]

Seconded on the cancer/surgery/pain front. The hydrocodone/acetaminophen they have me taking is more effective than hydrocodone alone, and in lower dose.

[Shroom Man 777]

Why is acetaminophen being made into some scary boogeyman? Over here paracetamol is a commonly used low-level analgesic and for fevers... from what I know, either the person has to have some kind of messed up condition or the dose has to be preposterously high before liver dosage is a consideration.

Is this just because acetaminophen has so many syllables and is hard to pronounce and spell? Jesus.

[Lord Revan]

Why is acetaminophen being made into some scary boogeyman? Over here paracetamol is a commonly used low-level analgesic and for fevers... from what I know, either the person has to have some kind of messed up condition or the dose has to be preposterously high before liver dosage is a consideration.

Is this just because acetaminophen has so many syllables and is hard to pronounce and spell? Jesus.

a lot people are willing to ban the use of water if you call it dihydro-oxide instead of the more common name what can I say people are stupid when it comes to these things.

[Broomstick]

That's a factor, but another one is that there is a certain faction out there that does take opiate containing products for recreational purposes, or as self-prescribed pain medications. Formulations containing acetaminophen are the most common and easily available, and that faction is a bit upset because while tolerance to morphine and the rest go up, tolerance for acetaminophen does not. It limits their "fun". Acetaminophen/paracetamol overdoses are in fact the most common cause of acute liver failure in the US and while a significant portion are complete accidents, and another slice of them are suicide attempts, there is a sub-group that is due to people sucking down pills in search of a high. That is the group that fancies the acetaminophen is mixed with the morphine to "punish" them. It's not. It's just that those pills are intended to relieve pain, not be recreational substances.

[Lord Revan]

Correct me if I'm wrong but isn't it so that "overdose" threshold for even pure opiates does not become that much higher as the resistance to the "high" portion of the drug grows so that eventually only to get high on morphine or similar opiate is to intentionally overdose (though obviously most people would never get to that point due to accidently overdosing before that).

[Broomstick]

No.

Back when I worked in drug rehab we had addicts on a maintenance dose, the "feel semi-normal and not in withdrawal dose", 2-3 times what would be the lethal dose in an "opiate-naive" individual. What they needed to get high was significantly more than that. The amount to overdose higher still.

I'm sure the ability to increase tolerance eventually levels off but it's way up there.

[mr friendly guy]

Off topic, how many countries actually call it acetaminophen as opposed to paracetamol. In Ecuador they prescribed me acetaminophen when I injured my arm and they told me ignoring the brand name its just acetaminophen. I mentioned this to the pharmacist and they didn't recognise it. I finally realised they also called it paracetamol, but the doctor just assumed my country would call it acetaminophen just like the north american countries.

[Dominus Atheos]

No.

Back when I worked in drug rehab we had addicts on a maintenance dose, the "feel semi-normal and not in withdrawal dose", 2-3 times what would be the lethal dose in an "opiate-naive" individual. What they needed to get high was significantly more than that. The amount to overdose higher still.

I'm sure the ability to increase tolerance eventually levels off but it's way up there.

Was there (I guess I should just call it "Tylenol" if Acetaminophen isn't universal) in those doses? One part of the conspiracy theory that sounded plausible was that the Tylenol would kill an addict through liver damage faster than morphine causing respiratory failure because tolerance to morphine increases to more you use it, while Tylenol tolerance stays the same.

[Broomstick]

The drug addicts I referred to used things like street heroin, diverted methadone, and the like, that was nearly 25 years ago. Prescription drugs - both prescribed and diverted - have become a much bigger thing since then.

In an "opiate-naive" individual taking something like my spouse's current Norco, for a one-time dose about 7-10 pills could cause an opiate OD (these things vary due to, among other things, bodyweight). You'd need about 12-15 of them to get to lethal Tylenol levels. For someone who has no developed tolerance for opiates the opiate OD would kill you first. However, someone with an opiate-tolerance (either due to medical side effects or addiction) might need 15-20, or more, of those pills to reach an opiate OD but the Tylenol OD remains the same... so yes, in opiate tolerant individuals it would most likely be the Tylenol that causes death.

Leaving aside there's no damn good reason to need 10 or more of those pills at one go - if you legitimately have that much of a pain problem there are better ways to medicate it. Such as the extended-release formulation of morphine prescribed for my spouse to be taken on a regular schedule. But he is, as I've said, a cancer patient and that's a lot different situation than, say, someone with chronic lower back pain.

[Knife]

Was there (I guess I should just call it "Tylenol" if Acetaminophen isn't universal) in those doses? One part of the conspiracy theory that sounded plausible was that the Tylenol would kill an addict through liver damage faster than morphine causing respiratory failure because tolerance to morphine increases to more you use it, while Tylenol tolerance stays the same.

Nugget of truth in there in that the dual meds ie: hydrocodone/APAP and Oxy/APAP used to come with the APAP at 500mg dose. So you'd have a norco or vikidin at say 5/500 dose. There was a huge push, at least in America, and everything got swapped over to 325mg dose of APAP in the combo drugs. Used to be the safe recommended daily dose of APAP was 4g. Any more and on average it would harm your liver. Which means on the old dosaging, you could only pop 8 pain pills a day to hit the max. Seems a lot but sometimes people were taking 2 pills every 6 hours means they hit that limit. If you needed every 4 hours, which is the lowest you're going to get shot of a few specified reasons, you're over on APAP.

The new recommended limit is 3g, though some docs still go with 4g, with 325 you're at the same amount of pills a day for pain but on a way lower daily dose. In a clinical setting, if that doesn't do it pain wise, they usually swap you over to just oxy IR or perhaps a patch, depending on the situation perhaps IV MS or hydromorphone. That said, the APAP is useful since it works differently than the narcs to relieve pain, so the combo drug is giving you two routes of pain relief.

That said, to the over all concerns, respiratory depression, let alone distress, is a larger problem and is related to the narc than the long term problem of liver failure. It takes either a shit load of APAP in short time or a very long time of being over the daily limit to do serious damage with APAP. Overdose and respiratory distress is more acute and more a threat to your life.

Oh, to Boomstick, nausea can be a side effect to APAP. GI upset and all that as well with too much tylenol in your gut, though you're right the nausea from opiods are a bit different.

[Flagg]

As someone who a decade ago after being gutted in FL did technically abuse Vicodin after I was discharged and went home (after 6 weeks of fucked up Twilight Zone hell ) until I ran out (I was taking it for the surgical pain. I wasn't taking a higher dose to get my jollies, just taking a larger dose than prescribed because I'm a big guy and the prescribed dose wasn't doing enough so I took 3 every 4 hours rather than 2, which is still abuse, but it wasn't crushing it up and snorting it or injecting it), there are varying levels of Tylenol in each pill just as there are different levels of hydrocodone.

At the time the max dose of Tylenol considered safe was 8000mg a day, now it's 6000mg. The 2 drugs are not combined in some conspiracy to kill addicts (though considering the US Government put poison in "bathtub" liquor during prohibition it's not beyond them to do something like that.) it's because it just works better with Tylenol, just like Percocet which is oxycodone with Tylenol. the hydrocodone doses per pill are 5mg, 7.5mg, or 10mg and the Tylenol is usually between 250mg-500mg (500mg is the dose in your normal regular OTC Tylenol pill).

[FireNexus]

My husband is currently undergoing treatment for cancer. His two main pain medications are pure morphine sulphate (extended release) and something called "norco", which is an opiate (hydrocodone) and acetaminophen. He consistently reports greater relief of acute pain with the combination, and will choose the combination over a higher dose of just the morphine.

I'd point out (someone like mr friendly guy with actual medical experience can backs up or tell me I'm stupid and wrong) that it might be more about a preference for hydrocodone than morphine. I think hydrocodone is about equipotent to morphine for analgesia (maybe slightly more or less, but not enough to super matter either way) but it has a more favorable side effect profile.

If his pain is from something is the abdominal region, the morphine might be less effective because of a particular nasty morphine side effect some people get (I'm one of them) from taking it orally. I've had IV morphine and morphine sulfate pills, and the pills give me violent abdominal spasms. Same thing happens when I take codeine (morphine prodrug) as well. Hydrocodone, hydromorphone, oxycodone, etc. have never caused that particular reaction in the times when what were in light of our current opioid crisis alarmingly negligent doctors wrote me prescriptions. (They don't give prescriptions for heroin, but knowing what I know about it's metabolic fate, I imagine it'd have me clutching my tummy, too)

If he has a more mild form of that "allergy" to morphine, he might report greater pain relief from hydrocodone Tylenol combos because hydrocodone doesn't cause spasms which increase his base pain level while relieving it neurologically. Especially in light of Tylenol being a barely effective pain reliever. You're right that the intention is greater pain relief without regard for abusers rather than "well tuck those guys" but I'd be surprised if the data actually supports a therapeutic benefit from the combination.

*It should be noted that the anti-abuse mindset did play a part in the legal treatment of opiod acetaminophen combination pain relievers for a while. Gradually, they stopped being treated specially, but Vicodin/Nortab used to be consider a smaller risk of abuse than pure hydrocodone formulations, and had a less stringent classification under the CSA. This decision was obviously made well after the design phase, though.

[Flagg]

I'm on hydromorphone (dilaudid) for my constant chronic abdominal pain that I require otherwise I wouldn't be able to eat or drink anything without pain so unbearable that I just stop eating and drinking (I'm talking even saltines and fresh from the tap bottled "spring water") because even a sip of the water would make me turn beet red and get so hot I could be in below freezing temps and feel like I was in 101 degrees f and be sweating bullets.

But my dental pain was managed better with other prescriptions.

[PainRack]

The drug addicts I referred to used things like street heroin, diverted methadone, and the like, that was nearly 25 years ago. Prescription drugs - both prescribed and diverted - have become a much bigger thing since then.

In an "opiate-naive" individual taking something like my spouse's current Norco, for a one-time dose about 7-10 pills could cause an opiate OD (these things vary due to, among other things, bodyweight). You'd need about 12-15 of them to get to lethal Tylenol levels. For someone who has no developed tolerance for opiates the opiate OD would kill you first. However, someone with an opiate-tolerance (either due to medical side effects or addiction) might need 15-20, or more, of those pills to reach an opiate OD but the Tylenol OD remains the same... so yes, in opiate tolerant individuals it would most likely be the Tylenol that causes death.

Leaving aside there's no damn good reason to need 10 or more of those pills at one go - if you legitimately have that much of a pain problem there are better ways to medicate it. Such as the extended-release formulation of morphine prescribed for my spouse to be taken on a regular schedule. But he is, as I've said, a cancer patient and that's a lot different situation than, say, someone with chronic lower back pain.

Once you get up to those dosages, its time to consider localised painkillers like nerve blocks or devices that deliver opioids directly to the damaged region and etc.

Its...vastly different from non cancer pain treatment though, which focuses on rehab.... Which sucks balls for stuff like joint pain. Someone telling you your arthritis would be better if you go through hell first(PT) AND lose weight is...well, theres a reason why pills and surgery sounds nicer

[Knife]

Oh yeah. Just did a 2 and a half year stint in a physical rehab hospital. People want pills and hate the idea of 'pushing through the pain' for rehab even though in the long run it is more effective for back/knee/hip pain.

I'll also add, due to the rampant abuse, know some nurses in other departments like ER who say their docs are being very stingy with opiods lately. My friends are getting some nasty looks and talk back when they come in with a Tylenol for pain but the docs won't order more unless something major is happening.

[Flagg]

Oh yeah. Just did a 2 and a half year stint in a physical rehab hospital. People want pills and hate the idea of 'pushing through the pain' for rehab even though in the long run it is more effective for back/knee/hip pain.

I'll also add, due to the rampant abuse, know some nurses in other departments like ER who say their docs are being very stingy with opiods lately. My friends are getting some nasty looks and talk back when they come in with a Tylenol for pain but the docs won't order more unless something major is happening.

When I broke 2 bones in my right hand, that were misplaced, the Doctor gave me extra strength Tylenol and referred me to a hand surgeon. When I asked about it she said something really snotty I'd have slugged anyone but a female (because I don't hit women) or a Doctor (I don't need to get a trespass order for the local ER) for given the situation. Good thing I didn't go into shock.