What are the risks of taking Tylenol (acetaminophen) for chronic pain?

From the Guidelines

Acetaminophen (Tylenol) should be used cautiously for chronic pain due to several significant risks, and the maximum daily dose should not exceed 4g, as recommended by the FDA 1.

Risks Associated with Acetaminophen Use

• Long-term use can cause liver damage, especially at doses exceeding 3,000-4,000 mg daily or when combined with alcohol.
• People with existing liver disease, alcohol use disorder, or those taking other medications metabolized by the liver face higher risks.
• Additional concerns include potential kidney problems with long-term use, masking underlying conditions requiring different treatment, and reduced effectiveness over time.

Recommendations for Safe Use

• For chronic pain management, it's recommended to stay below 3,000 mg daily (typically no more than 6 regular-strength 325 mg tablets or 4 extra-strength 500 mg tablets in 24 hours).
• Take the lowest effective dose, and avoid daily use beyond a few weeks without medical supervision.
• Regular monitoring of liver function is advisable during extended use, and alternative pain management strategies should be considered for chronic conditions.

Considerations for Patient Education

• Patients should be aware of the risks of taking additional over-the-counter products containing acetaminophen when prescribed formulations that combine opioids with acetaminophen 1.
• Discuss effects that opioids might have on ability to safely operate a vehicle or other machinery, particularly when opioids are initiated, when dosages are increased, or when other central nervous system depressants, such as benzodiazepines or alcohol, are used concurrently.
• Emphasize improvement in function as a primary goal and that function can improve even when pain is not eliminated 1.

From the FDA Drug Label

WARNINGS Liver warning: This product contains acetaminophen. Severe Liver damage may occur if you take • more than 6 caplets in 24 hours, which is the maximum daily amount • with other drugs containing acetaminophen • 3 or more alcoholic drinks everyday while using this product Allergy alert: acetaminophen may cause severe skin reactions Symptoms may include: • skin reddening • blisters • rash If a skin reaction occurs, stop use and seek medical help right away

The risks of taking Tylenol (acetaminophen) for chronic pain include:

• Severe Liver damage if more than 6 caplets are taken in 24 hours, or if taken with other drugs containing acetaminophen, or with 3 or more alcoholic drinks every day
• Severe skin reactions, including skin reddening, blisters, and rash, which require immediate medical attention if they occur 2 It is also important to note that the drug label advises not to use acetaminophen for more than 10 days unless directed by a doctor 2

From the Research

Risks of Taking Tylenol for Chronic Pain

The use of Tylenol (acetaminophen) for chronic pain management has been a subject of interest in various studies. While it is commonly recommended as a first-line therapy for pain management, there are potential risks associated with its long-term use. Some of the key risks include:

• Hepatotoxicity: Although the risk of hepatotoxicity is rare when acetaminophen is used as directed, it is still a concern, especially for patients with pre-existing liver disease 3, 4, 5.
• Gastrointestinal bleeding: Chronic use of acetaminophen has been associated with an increased risk of gastrointestinal bleeding, with the evidence showing a degree of dose dependence 6.
• Increased blood pressure: Long-term use of acetaminophen has been linked to a small increase in systolic blood pressure, which may be a concern for patients with pre-existing hypertension 6.
• Renal injury: There is some evidence to suggest that chronic acetaminophen use may be associated with renal injury, although the evidence is not as strong as it is for gastrointestinal bleeding and increased blood pressure 6.
• Cardiovascular disease: The relationship between chronic acetaminophen use and cardiovascular disease is still being studied, with some evidence suggesting a potential link 6.

Special Considerations

Certain patient populations may require special consideration when using acetaminophen for chronic pain management, including:

• Patients with liver disease: While acetaminophen can be used safely in patients with liver disease at recommended doses, it is essential to monitor liver function and adjust the dose as needed 3, 4, 5.
• Older adults: There is no evidence to support routine dose reduction for older adults, but dosing should be individualized in consultation with a physician, especially for those with decompensated cirrhosis, advanced kidney failure, or analgesic-induced asthma 4.
• Patients with kidney disease: Acetaminophen can be used safely in patients with kidney disease, but the dose may need to be adjusted based on the severity of the disease 4, 5.