First, on names: we’ve titled this with “Tylenol” because that’s a well-known brand name, but the drug name is paracetamol or acetaminophen:

• paracetamol is the drug name used by the World Health Organization, and thus also most countries.
• acetaminophen is the drug name used in Canada, Colombia, Iran, Japan, US, and Venezuela.

They are absolutely the same drug.

Firstly, obviously, do avoid overdose

The safe dosage described on the packet is generally accurate (usually around 4g/day, spaced out at 1g per 4 hours), and the dose required for toxicity is generally about 10g, or 200mg/kg body weight, whichever is lower. Since a single dose usually contains 2x 500mg = 1g, that makes overdose all too easy.

The amount required for toxicity can be misleading too, because that’s assuming…

• a healthy liver
• no other health problems
• no other medications that interact or add to the toxicity
• no medications that strain the liver (as with many pro-drugs, and drugs in general that are metabolized by the liver, which is lots).

Which is a lot of assumptions! Especially given that the liver can only process so much at once, meaning that if your liver has a lot of things to do, it can get a backlog, and you think “I’m not taking anything with this painkiller that I shouldn’t” but your liver is still metabolizing the last of last night’s glass of wine and one of your regular medications from this morning, because previously it was still metabolizing things from the day before yesterday, and so on.

See also: How To Regenerate Your Liver ← the liver is an incredible organ that does an amazing job, but it can’t do that if you don’t do this

Please don’t overdose deliberately either. Intentional overdoses make up a very large portion of acetaminophen overdoses (exact figures vary from year to year and place to place, but it’s always high), and what a lot of people doing that don’t realize is:

1. it’s a very unpleasant way to die. You’ll take it, you might get some initial symptoms within the first hours or you might not, then you’ll probably feel better, and then the next day or so, you’ll enter the organs-shutting-down stage that usually will take most of a week to kill you slowly and painfully. Often your kidneys will go first but it’ll usually be liver necrosis that deals the final blow.
2. it’s very difficult to treat. Stomach-pumping might work if you get it within 1 hour of overdose, and activated charcoal might help if you get it within 2 hours. Acetylcysteine may reduce the toxicity if you get it within the 8–48 hour window (depending on the speed of gastric emptying), but whether or not that will help depends on the severity of the overdose and other factors, so this is not something to bet on. After 48 hours, a liver transplant is the last resort, without which, mortality is around 95%.

Unfortunately, this means that a lot of people who do not fully intend to die horribly, and hoped to either die peacefully or else be saved, die horribly instead.

Ok, that was not a cheerful topic but it is important, before moving on, we’ll just put this here for anyone it may benefit:

How To Stay Alive (When You Really Don’t Want To) ← this is about suicidality, in yourself or others

Secondly, that dosage is for occasional use only

The problem often starts like this:

❝Due to its perceived safety, paracetamol has long been recommended as the first line drug treatment for osteoarthritis by many treatment guidelines, especially in older people who are at higher risk of drug-related complications❞

People with chronic pain, whether high or low on the pain level of that chronic pain, can very easily get into a habit of “I’ll just take this to take the edge off”, for example when getting up in the morning (often a trigger for pain starting) or going to bed at night (one needs to sleep and the pain is a barrier to that).

But… Those events, getting up and going to bed, it means that taking the drug also becomes part of one’s morning/evening routine—with many people even metering the doses out into pill organizers for the week, with this in mind.

A large (n=582,961) study looked at two groups of people, all aged 65+:

• 180,483 people who had been prescribed paracetamol repeatedly (≥2 prescriptions within six months)
• 402,478 people of the same age who had never been prescribed paracetamol repeatedly

The findings? Bearing in mind that “≥2 prescriptions within six months” is not something generally considered excessive…

❝Acetaminophen use was associated with an increased risk of peptic ulcer bleeding (aHR 1.24; 95% CI 1.16, 1.34), uncomplicated peptic-ulcers (aHR 1.20; 95% CI 1.10, 1.31), lower gastrointestinal-bleeding (aHR 1.36; 95% CI 1.29, 1.46), heart-failure (aHR 1.09; 95% CI 1.06, 1.13), hypertension (aHR 1.07; 95% CI 1.04, 1.11), and chronic kidney disease (aHR 1.19; 95% CI 1.13, 1.24).❞

The researchers concluded:

❝Despite its perceived safety, acetaminophen is associated with several serious complications. Given its minimal analgesic effectiveness, the use of acetaminophen as the first-line oral analgesic for long-term conditions in older people requires careful reconsideration.❞

You can see the study itself here: Incidence of side effects associated with acetaminophen in people aged 65 years or more: a prospective cohort study using data from the Clinical Practice Research Datalink

What to use instead?

It’s been established that taking aspirin regularly isn’t great either:

See: Low-Dose Aspirin & Anemia and Aspirin, CVD Risk, & Potential Counter-Risks

And as for ibuprofen, we don’t have an article about that yet, but it’s gut-unhealthy (harms your microbiome), and besides, anything it can do, ginger can do as well or better (in head-to-head trials; we’re not speaking hyperbolically here):

Ginger Does A Lot More Than You Think ← in fact, it was even found as effective as the combination of acetaminophen, ibuprofen, and caffeine

There are other options though, and as pain is complicated and there’s no one-size-fits-all solution, we’ve compiled the following:

• Dial Down Your Pain
• Stop Pain Spreading
• Managing Chronic Pain (Realistically!)
• The 7 Approaches To Pain Management
• Science-Based Alternative Pain Relief ← when painkillers aren’t helping, these things might

Take care!