Go Easy on the Tylenol

Tylenol, good and bad. Photo by Andrea Piacquadio from Pexels

I can remember some years back when doctors were accused in the lay press of being callous and not treating patients' pain with sufficient narcotics.  Prompted by the opioid crisis over the last several years, the pendulum swung in the opposite direction, and now over-prescription of narcotics is a hot topic.  High profile legal cases including that of Purdue Pharmaceuticals and individual physicians who illegally or quasi-legally prescribed enormous amounts of narcotic medication have made many headlines.  Changing standards of care and legislative measures have put many new restrictions on how narcotics are prescribed.  

This restriction of narcotics has made surgeons look more to alternatives, or non-narcotic adjuncts to help with postoperative pain and reduce the need for narcotics.  These drugs may belong to several different classes of medication, but the most common ones include old standbys like acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.  Commonly, a narcotic is paired with acetominophen.  For example, Norco and Vicodin are combinations of the narcotic hydrocodone with acetaminophen.

Acetaminophen as surgical pain relief

I routinely have my patients take 1000 mg of acetaminophen by mouth immediately prior to surgery, after they arrive at the surgery center.  This reduces the need for narcotics during and immediately after surgery.  But acetaminophen has a nasty side effect of liver toxicity with the recommended maximum dose being 4000 mg per day.  I like to tell my patients to keep it under 3000 mg per day, especially for a smaller person.  Each Norco or Vicodin pill typically has 325 mg of acetaminophen.  So even if someone was taking the maximum prescribed dose of 2 pills every 6 hours (2600 mg), they'd be under my 3000 mg/day limit.  

Surgical patients should begin to taper their narcotic use as soon as they can and usually within the first 48 hr after surgery.  Beginning to add acetaminophen or a NSAID can help that happen, but only if the acetaminophen-containing narcotic pill is being dialed back!  If not, the dose limit can be exceeded.

Acetaminophen as fever reducer

Acetaminophen is given far too often by physicians and parents for fever reduction.  Fever is one of the body's natural defenses against bacteria and viruses.  Although acetominophen is routinely given as a comfort measure for low fevers, there is plenty of evidence that this is harmful, or at least prevents the immune system from mounting a proper response.  Another concern regarding overuse of acetaminophen is its depletion of glutathione, a vital antioxidant in your cells. 

Fever reduction with acetominophen should probably be avoided for fevers under 103 degrees.  I have been surprised to hear from people who have had Covid that they have been told to take acetominophen at the first sign of a fever! Fever helps fight infections including respiratory infections.  Early mild fevers after surgery are common and some acetominophen is fine for comfort, but skip it if you can.  The rare surgical infection usually manifests several days after surgery, and is usually diagnosed by examination of the wound, as a fever may or may not be present.


Douglas J. Mackenzie, MD

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