The Limits of Tylenol for Pain Relief

April 16, 2015
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Tylenol Ineffective for Treating Back Pain, Quadruples the Risk of Liver Damage

A new review of 13 studies found that widespread recommendations for treating back-pain and osteoarthritis patients with acetaminophen need to be reconsidered. The study found "high-quality evidence" that acetaminophen is ineffective for treating low back pain and had only a small effect in patients with osteoarthritis.

That small effect was "not likely to be meaningful for clinicians or patients," the researchers wrote. In addition, acetaminophen use increases the risk of having an abnormal result on liver function tests by nearly fourfold.⁴ According to researchers:

"We found that paracetamol [acetaminophen] is ineffective on both pain and disability outcomes for low back pain in the immediate and short term and is not clinically superior to placebo on both pain and disability outcomes for osteoarthritis.

…Our results therefore provide an argument to reconsider the endorsement of paracetamol in clinical practice guidelines for low back pain and hip or knee osteoarthritis."

Acetaminophen Can be Deadly

Given the fact that acetaminophen is one of the most widely used drugs in the world, you might be surprised to learn that taking just a bit too much on a regular basis, or taking it in combination with alcohol, can have rather significant health risks.

Acetaminophen overdose is the leading cause for calls to Poison Control Centers across the US—more than 100,000 instances per year—and acetaminophen poisoning is responsible for nearly half of all acute liver failure cases in the US.⁵

Acetaminophen overdoses are also responsible for more than 150 deaths each year in the US.⁶ A major problem is that while acetaminophen is considered safe when taken as recommended, the margin between a safe dose and a potentially lethal one is very small.

Taking just 25 percent more than the daily recommended dose—the equivalent of just two extra strength pills per day—can cause liver damage after just a couple of weeks of daily use.⁷

When taken all at once, just under four times the maximum daily dose can be lethal. Previous research has also shown that taking just a little more than the recommended dose over the course of several days or weeks (referred to as "staggered overdosing") can be more risky than taking one large overdose.⁸

In 2009, the US Food and Drug Administration (FDA) finally added a warning to acetaminophen-containing drugs alerting consumers to its potential for causing liver damage—a move recommended by an expert panel all the way back in 1977!

Then, in 2013, the agency warned that acetaminophen may cause three serious skin reactions, two of which typically require hospitalization and can be fatal. Last year, the FDA issued a statement urging doctors and other health professionals to stop prescribing and dispensing prescription combination drug products that contain more than 325 milligrams (mg) of acetaminophen per tablet, capsule, or other dosage unit.⁹

One of the problems with relying on medications to treat pain, especially chronic pain, is that the side effects can sometimes be worse than the condition you're trying to treat. This is even sometimes the case with seemingly "safe" medications like acetaminophen. Your risk of severe liver injury and/or death related to acetaminophen increases if you:

Take more than one regular strength (325 mg) acetaminophen when combined with a narcotic analgesic like codeine or hydrocodone
Take more than the prescribed dose of an acetaminophen-containing product in a 24-hour period
Take more than one acetaminophen-containing product at the same time. Make sure to read the list of ingredients on any other over-the-counter (OTC) or prescription drug you take in combination.
Drink alcohol while taking an acetaminophen product. Research suggests that acetaminophen significantly increases your risk of kidney dysfunction if taken with alcohol—even if the amount of alcohol is small.¹⁰ Combining alcohol with acetaminophen was found to raise the risk of kidney damage by 123 percent, compared to taking either of them individually. Besides alcoholics, young adults are particularly at risk as they're more likely to consume both.¹¹

Past Research Also Found Acetaminophen Doesn't Work for Back Pain

Research published in 2014 also found that taking acetaminophen for back pain is no more effective than taking a placebo.¹² As reported by Fortune Magazine:¹³

"Conducted at hundreds of clinics in Sydney, Australia, the study tracked 1,652 individuals with lower back pain for four weeks. They were given either paracetamol (what acetaminophen is known as overseas), or a placebo.

In the end, researchers found there was almost no difference in the number of days required to recover between the two groups; the median time to recovery was 17 days in the regular paracetamol group, 17 days in the as-needed paracetamol group, and 16 days in the placebo group."

According to lead author Dr. Christopher Williams, "The results suggest we need to reconsider the universal recommendation to provide paracetamol [acetaminophen] as a first-line treatment for low-back pain..."

Unfortunately, back pain is also one of the leading causes for opioid addiction, which now claims the lives of 17,000 Americans each year. Prescription opioids have also become the latest "gateway drugs" to illicit drug use. It's important to realize that prescription medications like hydrocodone and oxycodone are opioid derivatives—just like heroin.

One in Four Chronic Pain Patients Misusing Opioids, One in 10 Addicted

In an accompanying editorial to the featured acetaminophen study, Christian Mallen and Elaine Hay of Keele University in England wrote that removing acetaminophen from existing treatment guidelines for back pain and arthritis might lead to an increase in the use of other powerful drugs, particularly addictive narcotics.¹⁴

Yet, misuse and addiction to such drugs has already reached epidemic levels. A new study published in the journal PAIN, for instance, found that one in four chronic pain patients may be misusing narcotic painkillers, and one in 10 may have formed an addiction.¹⁵ Dr. Andrew Kolodny, the chief medical officer at Phoenix House, a drug treatment provider, told Forbes:¹⁶

"Some people who become addicted develop the disease from misuse, but people can just as easily become addicted taking pills exactly prescribed … Once addicted, misuse (i.e. taking more pills than prescribed or crushing and snorting pills) becomes more common, but again, keep in mind that patients can still be addicted without misuse."

Opioids Often Cause More Harm Than Good for Chronic Pain

In 2014, the American Academy of Neurology updated their position statement on opioids, highlighting the problems of overuse. Over 100,000 people have died, directly or indirectly, from prescribed opioids in the US since the late 1990s. In the highest-risk group (those between the ages of 35 and 54), deaths from opioids exceed deaths from both firearms and motor vehicle accidents.

Pain is one of the most common health complaints in the US, but record numbers of Americans are, sadly, becoming drug addicts in an attempt to live pain-free. According to 2010 data, there were enough narcotic painkillers being prescribed in the US to medicate every single adult, around the clock, for a month.¹⁷ By 2012, a whopping 259 million prescriptions for opioids and other narcotic painkillers were written in the US, which equates to 82.5 prescriptions for every 100 Americans.¹⁸

The Academy of Neurology report notes that while such drugs may offer short-term relief for non-cancer chronic pain such as back pain, headaches, migraines and fibromyalgia, they cause more harm than good over time:¹⁹

"Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction."

Research has shown, for instance, that more than half of people who use opioids for three months will still be using them five years later.²⁰ Meanwhile, a study published in the New England Journal of Medicine found that long-term use of opioids actually does little to relieve chronic pain.²¹ In some cases, they may even make chronic pain worse. As TIME reported:²²

"…the opioids can backfire in excessive doses; in the same way that neurons become over-sensitized to pain and hyper-reactive, high doses of opioids could prime some nerves to respond more intensely to pain signals, rather than helping them to modulate their reaction."

The American Academy of Neurology is now calling for clear limits to be set on opioid use, especially for non-cancer pain. Certain states already have warnings in place that require physicians to seek other opinions if a person takes daily opioid doses of 80-120 mg without getting relief. Still, the pills shouldn't be viewed as a go-to treatment for chronic pain in the first place, as lifestyle changes, cognitive behavioral therapy, and other strategies are often more effective and far safer.

Medical Marijuana Offers Pain Relief While Driving Down Opioid Overdose Deaths

In states where medical marijuana is legal, overdose deaths from opioids like morphine, oxycodone and heroin decreased by an average of 20 percent after one year, 25 percent after two years and up to 33 percent by years five and six.²³ As the researchers explained:²⁴

"Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them… Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates."

There is a wealth of research linking marijuana with pain relief. In one study, just three puffs of marijuana a day for five days helped those with chronic nerve pain to relieve pain and sleep better.²⁵ If you're in pain, especially if it's severe, I realize that you may be desperate for relief. Prescription and over-the-counter painkillers do have their place in medicine, especially for short-term relief of severe pain (such as after surgery or serious injury). In certain cases, such drugs can be a great benefit when used cautiously and correctly with appropriate medical supervision.

However, it's also quite clear that these drugs are being overprescribed, and can easily lead you into addiction and other, more illicit, drug use, as well as cause other serious side effects. The overreliance on them as a first line of defense for pain is a major part of this problem. So if you are dealing with severe or chronic pain, my first suggestion would be to see a pain specialist who is familiar with alternative treatments and the underlying causes of pain. Ideally, it is best to find a knowledgeable practitioner who can help you attack the pain from multiple angles, giving you both relief and healing.

As mentioned, cannabidiol (CBD) in marijuana is an excellent painkiller and has been used successfully to treat a variety of pain disorders. If your pain is severe enough, it might even be worth moving to one of the many states where medical cannabis is legal, as it can be a real life changer. In states where medicinal marijuana is legal, such as California, you can join a collective, which is a legal entity consisting of a group of patients that can grow and share cannabis medicines with each other.

By signing up as a member, you gain the right to grow and share your medicine. I do, however, still recommend working with a health care practitioner who can guide you on the most effective dosage and form of use. While critics of medical marijuana (which, by the way, are in the minority, as 85-95 percent of Americans are in favor of medical cannabis, and 58-59 percent are in favor of legalizing marijuana) point out its risks, they pale in comparison to those of opioids. While some do become addicted, or at least dependent, on marijuana, it is far less addictive than prescription opioids.

19 Non-Drug Solutions for Pain Relief

I strongly recommend exhausting other options before you resort to an opioid pain reliever or even acetaminophen. The health risks associated with these drugs are great, and addiction to opioids is a very real concern. For instance, exercises, such as strengthening exercises, have been found to decrease pain more than short-term use of acetaminophen for hip or knee osteoarthritis.²⁶ And as Dr. Houman Danesh, director of integrative pain management at Mount Sinai School of Medicine in New York City, told WebMD:²⁷

"This [featured] study does suggest that other methods -- such as acupuncture, smoking cessation, weight loss, physical activity and proper ergonomics at our work stations -- may have an equal role to [acetaminophen] in treating back pain."

Below I list 19 non-drug alternatives for the treatment of pain. These options provide excellent pain relief without any of the health hazards that prescription (and even over-the-counter) painkillers carry. This list is in no way meant to represent the only approaches you can use. They are, rather, some of the best strategies that I know of. I do understand there are times when pain is so severe that a prescription drug may be necessary. Even in those instances, the options that follow may be used in addition to such drugs, and may allow you to at least reduce your dosage. If you are in pain that is bearable, please try these first, before resorting to prescription painkillers of any kind.

Eliminate or radically reduce most grains and sugars from your diet. Avoiding grains and sugars will lower your insulin and leptin levels and decrease insulin and leptin resistance, which is one of the most important reasons why inflammatory prostaglandins are produced. That is why stopping sugar and sweets is so important to controlling your pain and other types of chronic illnesses.
Take a high-quality, animal-based omega-3 fat. My personal favorite is krill oil. Omega-3 fats are precursors to mediators of inflammation called prostaglandins. (In fact, that is how anti-inflammatory painkillers work, they manipulate prostaglandins.)
Optimize your production of vitamin D by getting regular, appropriate sun exposure, which will work through a variety of different mechanisms to reduce your pain.
Emotional Freedom Technique (EFT) is a drug-free approach for pain management of all kinds. EFT borrows from the principles of acupuncture, in that it helps you balance out your subtle energy system. It helps resolve underlying, often subconscious, negative emotions that may be exacerbating your physical pain. By stimulating (tapping) well-established acupuncture points with your fingertips, you rebalance your energy system, which tends to dissipate pain.
K-Laser Class 4 Laser Therapy. If you suffer pain from an injury, arthritis, or other inflammation-based pain, I'd strongly encourage you to try out K-Laser therapy. It can be an excellent choice for many painful conditions, including acute injuries. By addressing the underlying cause of the pain, you will no longer need to rely on painkillers. K-Laser is a class 4 infrared laser therapy treatment that helps reduce pain, reduce inflammation, and enhance tissue healing—both in hard and soft tissues, including muscles, ligaments, or even bones.

The infrared wavelengths used in the K-Laser allow for targeting specific areas of your body, and can penetrate deeply into the body to reach areas such as your spine and hip. For more information about this groundbreaking technology, and how it can help heal chronic pain, please listen to my previous interview with Dr. Harrington.

Chiropractic. Many studies have confirmed that chiropractic management is much safer and less expensive than allopathic medical treatments, especially when used for pain, such as low-back pain. Qualified chiropractic, osteopathic, and naturopathic physicians are reliable, as they have received extensive training in the management of musculoskeletal disorders during their course of graduate healthcare training, which lasts between four to six years. These health experts have comprehensive training in musculoskeletal management.
Acupuncture can also effectively treat many kinds of pain. Research has discovered a "clear and robust" effect of acupuncture in the treatment of: back, neck, and shoulder pain, osteoarthritis, and headaches.
Physical and massage therapy has been shown to be as good as surgery for painful conditions such as torn cartilage and arthritis.
Astaxanthin is one of the most effective fat-soluble antioxidants known. It has very potent anti-inflammatory properties and in many cases works far more effectively than anti-inflammatory drugs. Higher doses are typically required and you may need 8 mg or more per day to achieve this benefit.
Ginger: This herb has potent anti-inflammatory activity and offers pain relief and stomach-settling properties. Fresh ginger works well steeped in boiling water as a tea or grated into vegetable juice.
Curcumin: In a study of osteoarthritis patients, those who added 200 mg of curcumin a day to their treatment plan had reduced pain and increased mobility. A past study also found that a turmeric extract composed of curcuminoids blocked inflammatory pathways, effectively preventing the overproduction of a protein that triggers swelling and pain.²⁸
Boswellia: Also known as boswellin or "Indian frankincense," this herb contains specific active anti-inflammatory ingredients. This is one of my personal favorites as I have seen it work well with many rheumatoid arthritis patients.
Bromelain: This enzyme, found in pineapples, is a natural anti-inflammatory. It can be taken in supplement form but eating fresh pineapple, including some of the bromelain-rich stem, may also be helpful.
Cetyl Myristoleate (CMO): This oil, found in fish and dairy butter, acts as a "joint lubricant" and an anti-inflammatory. I have used this for myself to relieve ganglion cysts and a mild annoying carpal tunnel syndrome that pops up when I type too much on non-ergonomic keyboards. I used a topical preparation for this.
Evening Primrose, Black Currant and Borage Oils: These contain the essential fatty acid gamma linolenic acid (GLA), which is useful for treating arthritic pain.
Cayenne Cream: Also called capsaicin cream, this spice comes from dried hot peppers. It alleviates pain by depleting the body's supply of substance P, a chemical component of nerve cells that transmits pain signals to your brain.
Medical cannabis has a long history as a natural analgesic, as mentioned.²⁹ At present, more than 20 US states have legalized cannabis for medical purposes. Its medicinal qualities are due to high amounts (about 10-20 percent) of cannabidiol (CBD), medicinal terpenes, and flavanoids. As discussed in this previous post, varieties of cannabis exist that are very low in tetrahydrocannabinol (THC)—the psychoactive component of marijuana that makes you feel "stoned"—and high in medicinal CBD. The Journal of Pain,³⁰ a publication by the American Pain Society, has a long list of studies on the pain-relieving effects of cannabis.
Methods such as yoga, Foundation Training, acupuncture, meditation, hot and cold packs, and other mind-body techniques can also result in astonishing pain relief without any drugs.
Grounding, or walking barefoot on the earth, may also provide a certain measure of pain relief by combating inflammation.