Is House headed for liver failure?

May 18, 2012 5:11 PM

At some point, I remember someone telling me that one of the reasons vicodin includes acetominophen in addition to hydrocodone was so that people trying to abuse Vicodin would suffer liver failure before the opioid abuse killed them. Wikipedia does not mention this, nor do the obvious Google queries. Can anyone confirm or deny this? And, more generally, what would be the ethical or business considerations that inform that decision?
posted by d. z. wang to health & fitness (13 answers total)

I haven't found a specific FDA report on it, but these previous links should help:

http://www.metafilter.com/82909/A-new-scare
http://www.metafilter.com/106199/But-what-about-Panadol-Anacin-and-Efferalgan

But I know what you're talking about. It's definitely more than insane conjecture.
posted by CrystalDave at 5:35 PM on May 18, 2012

[Folks, random speculation and non-answer remarks don't belong here. Thanks. ]
posted by restless_nomad at 5:41 PM on May 18, 2012 [3 favorites]

An alternate reason that Vicodin contains acetaminophen is that it works synergystically with codeine.
posted by zippy at 5:51 PM on May 18, 2012 [5 favorites]

The term I've heard/read is "potentiates", i.e., by combining acetaminophen with the hydrocodone you get more effect. This apparently works for other drugs too. I take tramadol for chronic pain and my rheumatologist instructed me I could take it simultaneously with acetaminophen to get more of an effect when the tramadol itself wasn't doing the job.
posted by SweetTeaAndABiscuit at 5:58 PM on May 18, 2012 [2 favorites]

I don't recall anything about that being the aim or intent of including acetaminophen, but I have read that that's why the combination of hydrocodone and acetaminophen is a commonly prescribed painkiller at Schedule III, while hydrocodone on its own is restricted to Schedule II along with methadone and morphine.
posted by WasabiFlux at 6:35 PM on May 18, 2012

Possibly relevant factoid... hydrocodone is used on the veterinary side of medicine, but is always without acetaminophen (our dog friends can't use tylenol). It is more useful to us as a cough suppressant than a big bullet pain management drug, which makes me suspect that the tylenol does potentiate the hydrocodone.
posted by Nickel Pickle at 7:04 PM on May 18, 2012

I asked my doctor about this once, and he said to me that it doesn't make any sense. Liver damage from acetaminophen overdose is basically fatal whereas opioid overdose is... well, less consequential at similar doses.

In other words, if you take 10 pills, the acetaminophen kills you while the hydrocodone just gets you high. From a hippocratic perspective, it is better to just let you get high.

He told me that they work well in tandem - the acetaminophen helping to reduce inflammation and swelling and the opioid working to reduce pain.

It could be that he's in on the scam, I guess. I don't know enough about it to say.

I don't know why people take vicodin recreationally - it's a nightmare of phantom itching and muscle spams at a regular dose. That shit sucks. That might be just me, but still....
posted by Pogo_Fuzzybutt at 7:29 PM on May 18, 2012 [2 favorites]

Well, on a purely logical basis, if drugs were designed as fatal boobytraps for addicts (and liver failure from acetaminophen overdose would count as such - it's just about as bad as a opioid overdose), then how would it be any use for "non-addicts" who need it on a longer-term basis for, say, post-surgical pain or whatever? You can't really mark drugs like you put those anti-theft ink tags on clothing.

My impression is that, yeah, it's due to the synergistic effects, or you're hitting the pain from two angles, both the opioid receptors and the cyclooxygenases.
posted by vetala at 8:35 PM on May 18, 2012

A physician friend of mine (since deceased) told me that this is how the "schedules" of the CSA were mapped out in congress. Tylenol w/ Codeine was placed in the most liberal "schedule" (for opiates), because, as was determined in congressional testimony, one "would die [of acetominophen poisoning] before becoming an addict" or words to that effect.
posted by telstar at 8:52 PM on May 18, 2012

Consider how many people abuse Vicodin worldwide these days... now, do you really think that the threat of liver failure is stopping them?

Yes, if you take more than 4 grams of acetaminophen in a day (which is 8 normal strength Vicodin) you risk liver damage. However, there are still a heck of a lot of people who are addicted to or dependent on Vicodin who take 8 or less of them per day (some of whom are very legitimately dependent on Vicodin due to painful medical conditions).

There are medications for which additives are intended to deter people from overdosing on the medication, but Vicodin is not one of them, and it wouldn't make sense to use acetaminophen as a deterrent. Many people aren't aware of how deadly Tylenol overdose is, so this probably won't scare them into avoiding Vicodin. Also, rather than just producing unpleasant side effects like nausea or vomiting, Tylenol in overdose can actually kill you.

Drug companies can be pretty cold and calculating, but they don't formulate drugs designed to kill or punish people. In fact, doctors and the FDA are pushing for cutting down the amount of acetaminophen in combination drugs because of the number of accidental Tylenol overdoses every year. We consider oxycodone to be safer because it is uncoupled from the acetaminophen that is in Percocet.

Even if, as a system, we did want to punish people for abusing drugs, it wouldn't make sense to do so by giving them liver failure. Liver failure is an incredibly expensive disease to treat because it requires ICU level care, liver transplantation, and then lifelong immunosuppressant medication for transplant recipients. Most people who OD on narcotics just sleep it off, sometimes for 1 night in the ICU to monitor their respiratory status, but rarely needing more than that. Much easier to let people die of respiratory failure from narcotic drugs, if you want to look at it from a cost to the system standpoint.
posted by treehorn+bunny at 11:31 PM on May 18, 2012 [1 favorite]

Interestingly enough, there're other analgesics besides opioids that contain acetaminophen. For example, the migraine drug Fioricet is a cocktail containing butalbital (a mid-acting barbituate), acetaminophen, and about a cup-of-coffee's worth of caffeine. It's a dangerous drug that's also a silver bullet solution for many migraineurs (including me).

In this case, the acetaminophen acts on pain receptors out of reach of the butalbital, possibly potentiating it as well. And caffeine can have a curative effect on migraines.

However, I suspect that the caffeine might also be included to keep potential abusers users awake and alert, avoiding an OD. I'm not sure that this is entirely the case, but the theory may hold water.

I've certainly never heard of anyone overdosing on Fioricet, despite the barbituate inside. And a non-caffeine version of Fioricet, though readily available a decade ago, seems to have mostly vanished from the market.

removes tin-foil hat
posted by Gordion Knott at 2:37 AM on May 19, 2012

Is it possible that you (or whoever told you about this) are confusing this with Atropine? That's something that IS added to opiate drugs(or at least one I know of) to discourage abuse. Acetaminophen overdose is notorious for doing its damage well below the radar - no unpleasant feelings till you're essentially beyond help. Atropine, on the other hand, dries out your mouth, makes it hard for some people to pee, and at higher doses makes your heart race unpleasantly. Who wants to abuse that med?
posted by wjm at 3:14 AM on May 19, 2012 [2 favorites]

For the US market, the reason that the pharma companies manufacture hydrocodone or oxycodone along with acetaminophen is because hydrocodone/oxycodone by themselves are Schedule II drugs, but when mixed with acetaminophen they become Schedule III drugs by law.

Less restrictive scheduling means, for instance, that prescriptions and refills for Vicodin can be called in to a pharmacy by a doctor. A Schedule II drug requires a physical copy of a legitimate written prescription to be dispensed and I don't think it's possible to include refills on schedule II drugs, although that could differ per state. Also, depending on the jurisdiction, certain medical professionals (Nurse Practitioners in particular) can write prescriptions for Schedule III and lower medications.

The ethics of this are terrible as far as I'm concerned because there's no sense in giving everyone who needs the pain relief that comes with opiates an additional hepatotoxin as some form of moral cudgel in the "war on drugs" (because liver toxicity is somehow preferable to recreational use of opiates). I completely understand the business decision to sell a Schedule III vs a Schedule II though, just because it means easier access and less restrictions on production. If, for instance, a pharma company decided they would rather do the right thing and not subject everyone to tylenol they don't need for the hydrocodone they do need, the pharma company would probably find its access to the raw materials needed to produce the Schedule II version severely limited by the DEA's quota limitations.
posted by ndfine at 9:08 AM on May 19, 2012