The toxicity of acetaminophen to your liver is well known. Currently some 38% of cases of acute liver failure are due to acetaminophen ingestion. You can get liver failure from taking 15 extra strength tylenol (containing 500 milligrams of acetaminophen) a day or from as few as 4 if you have liver damage from . This liver failure is insidious. Once it starts, it can quickly progress to the point where you feel fine but will be dead in a matter of days unless you have a liver transplant. By the time you feel desperately ill, it may be too late. If you have overdosed on tylenol and have abdominal pain, you need to get yourself to an emergency room quickly.

I remember being annoyed that in order to get effective pain relief I was being forced to take a liver toxin that added little to the pain relieving efficacy of the opiate. I speculated to my wife that there was probably more injury and death occurring from the acetaminophen than the "dangerous narcotic" in the Vicodin.

Now it looks like the FDA has recognized the same thing that was casually obvious to a radiologist more than 10 years ago. As recreational drug users and addicts seek Vicodin for it's narcotic benefits, and regular folks have acute pain, they are increasingly suffering inadvertent liver toxicity from acetaminophen, contributing to the 40,000 Emergency room visits per year related to acute liver injury.

From this article in the Wall Street Journal January 13, 2011:

Federal health regulators are restricting the amount of acetaminophen in prescription painkillers such as Vicodin and Percocet because of concerns that acetaminophen overdoses are linked to thousands of cases of liver damage in recent years.

The Food and Drug Administration said Thursday it will ask manufacturers to limit acetaminophen used in combination prescription drugs to 325 milligrams. The agency is also asking drug makers to add the strongest warning-a black box-to their labels about the possibility of severe liver damage.

What has all this to do with the war on drugs?

In the early days of the misguided, counterproductive and massively expensive "war on drugs", Richard Nixon signed the Drug Control Act that established "schedules" that doctors and patients must deal with today. The schedules range from IV to I, in order of their "abuse potential".

Just don't get confused and think that this had something to do with safety. Toxic chemotherapy agents, the blood thinner warfarin and many other very dangerous drugs are not on the schedule at all, but pretty much any drug someone might take at a party is.

It was decided that drugs should be made more difficult to obtain based on their potential for "abuse". In keeping with the moralistic and authoritarian origins of all this, "abuse" means "getting high" and has little to do with how dangerous the given drug is to your health. Some drugs, like , are schedule I and legally unavailable to anyone in most states. Does anyone really think cannabis is deadlier than Jim Beam?

This is how you end up with an unnecessary liver toxin in your narcotic. The government figures it has a lower potential for abuse because you will be dissuaded from taking enough of it to "get high' by the potential for hepatotoxicity due to the added acetaminophen! The manufacturer quite naturally responds to the perverse incentives of the Drug Control Act by adding the acetaminophen to get a schedule III classification. This makes it less onerous for the prescribing physician, and easier for the patient, resulting in greater sales for the drug company.

Make the potential party drug more toxic so it is less likely to be "abused".

In case you think my reasoning on this is overly cynical, have you ever purchased denatured alcohol at the hardware store? This is ethanol - the same kind found in your gin and tonic - which has been purposefully engineered to kill you if you drink it. "Denatured" implies there has been some chemical alteration of the alcohol, but in fact it is just intentionally contaminated with toxic industrial solvents like methanol or acetone.

The manufacturer goes to extra effort and expense to add poison for the sole purpose of escaping burdensome government regulation and taxation. And the government dissuades you from getting high with a legal drug by threatening you with death.

Still doubt that your government might be willing to burn the village in order to save it?

Read an article by Deborah Blum of Slate called The Chemist's War.

Here are some excerpts:

It was Christmas Eve 1926, the streets aglitter with snow and lights, when the man afraid of Santa Claus stumbled into the emergency room at New York City's Bellevue Hospital...

Before hospital staff realized how sick he was-the alcohol-induced was just a symptom-the man died. So did another holiday partygoer. And another. As dusk fell on Christmas, the hospital staff tallied up more than 60 people made desperately ill by alcohol and eight dead from it. Within the next two days, yet another 23 people died in the city from celebrating the season.....

Frustrated that people continued to consume so much alcohol even after it was banned, federal officials had decided to try a different kind of enforcement. They ordered the poisoning of industrial alcohols manufactured in the United States, products regularly stolen by bootleggers and resold as drinkable spirits. The idea was to scare people into giving up illicit drinking. Instead, by the time Prohibition ended in 1933, the federal poisoning program, by some estimates, had killed at least 10,000 people....

So I am glad the FDA is finally realizing what is going on, but it's too bad they don't address the true source of the problem, which is Prohibition II - the absurd war on drugs, the "schedule" and the perverse incentives such attempts at control always create.

Your government is determined to protect you from too much fun, even if it kills you.

Note: I advise requesting good old morphine when in the hospital, which is cheap, safe and effective, and requesting pure or maybe percodan if you really need it after discharge.

I don't advise taking any drugs for recreation.