The Most Dangerous of Safe Medications

Now that I’ve unloaded some high-grade alarmism on you, let’s take a deep breath and review the primary message. Acetaminophen is safe and effective when used as directed. Donald Miles, M.D., an urgent care physician with Dignity Health, puts it this way: “What I usually tell people is that this is not a benign drug. It has potential problems. We have to be careful, as with any other medication. I always tell them never take more than what is recommended,” says Miles. “If taken as directed, either by your primary care physician or the label on the package, you’re much less likely to have any problems. It’s a drug with a strong safety record that will do what it’s supposed to do.”

As a tippler and occasional Tylenol taker, I had to ask the doctor if it’s possible my liver or kidneys have been damaged and I don’t know it. He reassures me it’s unlikely sporadic doses and the occasional alcoholic beverage would result in long-term damage. Nevertheless, he issues a precaution beyond the standard warning label.

“Several years ago, the FDA said people should not be taking maximum strength, because of the potential for problems, so we have been recommending regular strength Tylenol,” says Miles. “Avoid the ‘extra-strength’ doses.”

Of course, my interpretation of that advice is “Maybe go with ibuprofen instead. It might upset your stomach but probably won’t shut down your liver.”

Do you remember the Tylenol Cyanide Scare? In 1982, a series of poisoning deaths resulted from drug tampering in the Chicago area. The victims had all taken Tylenol-branded acetaminophen capsules that had been laced with potassium cyanide. Seven people died in the original poisonings, with several more in copycat crimes. It was a terrible and high profile incident, with a somewhat famous conclusion. Within a week, McNeil pulled 31 million bottles of tablets back from retailers, making it one of the first major product recalls in American history. It would eventually become one of the most frequently taught lessons in crisis management discussed in every MBA program on the planet. It ultimately positioned Tylenol as the paragon of corporate responsibility in the public eye. But McNeil’s record of responsibility is a bit murkier when closely scrutinized. Although it has taken some steps to protect consumers, including the launch of a “Know Your Dose” public awareness campaign, an in-depth 2013 report by ProPublica revealed McNeil had repeatedly opposed FDA safety warnings, dosage restrictions and other measures meant to safeguard users of the drug.

But making a boogeyman out of a pharmaceutical company is a dull oversimplification. What’s really puzzling is that even when people read and understand warning labels, they still make bad decisions. Consumer research conducted in 2015 by a team of professors from California State University and University of California showed that most adults (OK, adults like me) simply ignored warning labels and assumed taking high doses of over-the-counter drugs was risk-free.

Jesse Catlin, Ph.D., is an assistant professor of marketing at Sacramento State and one of the study’s three co-authors. He explains that the problem seems to come down to two human miscalculations.

“Most people refer to drugs by their brand name. Tylenol. NyQuil. Motrin. Advil,” says Catlin. “It could be that some people just don’t know what’s in the drug.” And yet lack of awareness of the active ingredient did not fully explain their behavior. “Even when people explicitly knew the same active ingredient was in two different medications, they didn’t seem to think that was a problem. So that led us to talk about what we call ‘the naive belief’ that over-the-counter meds are basically risk-free even when people don’t use them properly.”

So what is the public-health solution here? It’s hard to fi nd an easy answer. The research conducted by Catlin and his team looked specifically at whether bright-red warning icons or packaging that clearly says, “This contains acetaminophen” would change behavior. It did not.

“Our study suggested we need to go a little bit further to dispel the myth that these things can’t be harmful if you misuse them,” says Catlin. “It seemed we were able to move the needle a bit when we gave people information that not only does this contain acetaminophen, or any other active ingredient, but we specifically include information that double dosing isn’t necessarily a good idea.”

I don’t know about you, but I’ve learned my lesson here. I’ve been converted. I swear from now on I will read the directions. I will stick to the guidelines. Pain is no fun, but it sure beats a trip to the emergency room.