Overdoses ?

[Nobody]

Does anyone on this board have any medical knowledge of overdosing on painkillers ?
A friend of mine has an injured ankle and it has been sore for about a week, a few days ago he took 4 Paracetamol tablets (500mg) in one dose, the maximum dose is 2 tablets four hourly not taking more than 8 a day. He plans to take 5 before a rugby match tommorrow as he is desperate to play and said he would take a few more after the game. I said that it would damage his liver but he doesn't take the warnings seriously.
Does anyone know the extent of damage these overdoses can cause ?

[Rolfe]

IANAD, but this is not clever. The difference between dose and overdose for paracetamol is relatively narrow, and individual susceptibility varies. You might get away with accidentally taking four on one occasion, but to plan to take five after doing that, and then more, is really taking unnecessary risks. Also, while people recover from ODing on aspirin regularly, paracetamol is a different matter. It can totally destroy the liver and you're either getting a transplant or you're dead.

I'm not necessarily advocating this (except that my own doctor suggested to me that I should do it), but if he wants to go overboard, try a simultaneous dose (recommended rate) of paracetamol and ibuprofen.

Rolfe

[blutoski]

Does anyone on this board have any medical knowledge of overdosing on painkillers ?
A friend of mine has an injured ankle and it has been sore for about a week, a few days ago he took 4 Paracetamol tablets (500mg) in one dose, the maximum dose is 2 tablets four hourly not taking more than 8 a day. He plans to take 5 before a rugby match tommorrow as he is desperate to play and said he would take a few more after the game. I said that it would damage his liver but he doesn't take the warnings seriously.
Does anyone know the extent of damage these overdoses can cause ?

Only a doctor can be officially specific, but the literature suggests that this dose could do permanent damage to the liver in some vulnerable people. There are recorded deaths at 6g/day. 5 tablets would be just under half a potentially lethal dose (OTOH, 5 tablets is about 10% the typical lethal dose).

I'd say he's taking a small chance of liver damage, and very little chance of death.

[Cecil]

IANAD either, but from my (admittedly limited) knowledge of this, liver damage arises when the concentration of paracetamol reaches a level high enough to saturate the primary (nontoxic) metabolic pathway in the liver. This causes some of the paracetamol to be diverted into the secondary pathway, which metabolizes it into a toxic byproduct. IIRC this dose tends to be around 4-5g/day for most people (though I don't doubt that for some people it might be less). I do know that alcohol, even in very small amounts, drastically lowers the "safe" dose of paracetamol, probably down to about 2g/day. So, in my nonexpert opinion he is likely not doing any harm.

However, I don't see the point in this. My understanding is that there is a limit to the severity of pain that can be blocked by paracetamol, regardless of dose. I second Rolfe's suggestion that he combine ~1g paracetamol with ~600mg ibuprofen.

Paracetamol overdose is not the way to go. It involves a slow, painful death from the buildup of toxins in the bloodstream. And these aren't the kind of toxins that can be cleaned out by going on a juice fast for three days. ;)

[TruthSeeker]

IANAD, but I do know some things about pain....agree with the others about the dangers of paracetamol, the ceiling effect, and the idea of combining with ibuprofen.

My bigger concern, however, is playing on the injured ankle....he may be setting himself up to do far more serious damage which may lead to severe, permanent damage and chronic pain.

Doesn't seem worth it, to me at least.

He'd be much better off tending to his current injury with safe medication use and rest.

[epepke]

IANAD either, but from my (admittedly limited) knowledge of this, liver damage arises when the concentration of paracetamol reaches a level high enough to saturate the primary (nontoxic) metabolic pathway in the liver. This causes some of the paracetamol to be diverted into the secondary pathway, which metabolizes it into a toxic byproduct. IIRC this dose tends to be around 4-5g/day for most people (though I don't doubt that for some people it might be less). I do know that alcohol, even in very small amounts, drastically lowers the "safe" dose of paracetamol, probably down to about 2g/day. So, in my nonexpert opinion he is likely not doing any harm.

I don't know if it's even legal for a rugby player not to drink heavily. It's certainly strongly discouraged.

In any event, if he has ankle pain, he shouldn't be taking paracetomol at all. He should be taking an NSAID, such as naproxyn sodium, ibuprofen, or even aspirin. Preferably with codeine. Since you're in a country where they say "paracetomol" rather than "acetominophen," aspirin with codeine is probably available OTC. The concentrations of codeine are damn near homeopathic, but it does take the edge off.

Oh, yeah, IANAMD.

[Mojo]

Also, while people recover from ODing on aspirin regularly, paracetamol is a different matter. It can totally destroy the liver and you're either getting a transplant or you're dead. And by the time the symptoms actually show up, the damage is already done. If anyone thinks they may have taken an overdose of paracetamol they should seek treatment straight away.

Not a doctor either.

[Dragon]

And by the time the symptoms actually show up, the damage is already done. If anyone thinks they may have taken an overdose of paracetamol they should seek treatment straight away.

Not a doctor either.IANAD but Mrs D is a nurse - when in training she looked after a guy who had taken an OD of paracetamol and not sought immediate treatment. He realised he had done a stupid thing and he was looking forward to getting his life back on track. Four days later he was dead.

Nobody - do everything you can to discourage your friend from taking that much paracetamol - I think 5 before and more after the match are going to amount to an OD. IIRC 12 is all it takes to cause liver damage. Threaten to tell his coach, captain or whoever - you'll be doing him a favour.

[Dragon]

From Wikipedia (http://en.wikipedia.org/wiki/Paracetamol) Paracetamol single doses above 10 grams or chronic doses over 5 grams per day in a well-nourished non-consumer of alcohol, or above 4 grams per day in a poorly-nourished consumer of alcohol, can cause significant injury to the liver. Without timely treatment, paracetamol overdoses can lead to liver failure and death within days. Because of the wide over-the-counter availability of the drug, it is sometimes used in suicide attempts.So, 20 x 500mg tablets in one go or 10 tablets daily are enough to cause damage - I'd say he's definitely putting himself at risk.

[Physiotherapist]

It is really not sensible to be thinking of playing a rugby match with an ankle injury. Two weeks is out of the so called 'acute' phase of healing, but it needs gentle mobilisation, not a rugby match where there is the possibility of re-traumatisation. Those collagen fibres can be easily disrupted again.

Also, trauma causes an inflammatory process to occur in the body, so taking ibuprofen is much more beneficial than taking paracetamol on its own. Also, I would think that taking that much paracetamol is not good. Paracetamol is hepato-toxic and there is a very fine line between a normal dose and an overdose.

My advice - don't play in the rugby game and continue to use R I C E - Rest, Ice, Compression and Elevation. Take Ibuprofen as indicated if it is still painful and then use gentle mobilisation. Go and see a physio or physical therapist or sports massage therapist who will use gentle mobilisation techniques and massage that will prevent scar tissue formation and so aid the healing process. This can also help to prevent the development of osteo arthritis around the joint in later life.

[athon]

Paracetamol is not a friendly drug. Liver failure can occur easily and suddenly in cases of overdose, and as has been pointed out by several people already, overdosing is a fine line.

The problem is you don't really go from 'sick' to 'sicker' to 'I feel we should go to hospital'. You go from feeling ok to liver failure to dead, essentially. Cecil gave a rather good description of the metabolism and pathology behind it.

I once tested an adolescent's blood for overdose of an unknown drug. Alcohol was evident on his breath, but he was being stubborn more than drunk. I calculated he must have taken at least 12, possibly 15 tablets in an suicide attempt. With the alcohol, he was lucky to survive. He claimed to be feeling ok and tried to check himself out. If he hadn't been convinced to stay, he would have gone home and died. His liver shut down overnight and he went into critical care for several days.

Nope, not pretty.

Athon

[Physiotherapist]

Whilst my wife was still nursing, before training as a midwife, she did a spell on liver HDU. She would tell me that they used to get some kids in who would take paracetamol as a cry for help, rather than really wanting to commit suicide. Some took as few as 8 to 10 at one time and would end up sick. They would be given the antidote drug, but at times this would be too late and unfortunately, some ended up in liver failure and with hepato-renal syndrome and also needed dialysis because of this. If they were lucky, some livers recovered, but others needed a transplant.

As has been pointed out already, it is a fine line and you can go from feeling well to collapsing and being seriously ill in a matter of hours. No intermediate at all.

[Ladewig]

He plans to take 5 before a rugby match tommorrow as he is desperate to play and said he would take a few more after the game.


So, what happened?

[luchog]

Whilst my wife was still nursing, before training as a midwife, she did a spell on liver HDU. She would tell me that they used to get some kids in who would take paracetamol as a cry for help, rather than really wanting to commit suicide. Some took as few as 8 to 10 at one time and would end up sick. They would be given the antidote drug, but at times this would be too late and unfortunately, some ended up in liver failure and with hepato-renal syndrome and also needed dialysis because of this. If they were lucky, some livers recovered, but others needed a transplant.
I know someone who did just this. IIRC he took roughly 20 OTC-strength tablets, a bit more than Nobody's friend is planning on taking. He ended up in the hospital within hours, with acute liver failure. I don't recall whether he recovered any liver function, or needed a transplant; since, shortly after this, i quit hanging out with anyone who might have known.

[deadrose]

I know someone who did just this. IIRC he took roughly 20 OTC-strength tablets, a bit more than Nobody's friend is planning on taking. He ended up in the hospital within hours, with acute liver failure. I don't recall whether he recovered any liver function, or needed a transplant; since, shortly after this, i quit hanging out with anyone who might have known.

If you're referring to L.'s husband, he had a transplant. He's currently back in the hospital, having just had an appendectomy. The anti-rejection drugs suppress his immune function so badly that he'll be prone to horrible infections for the rest of his life.

All because of a toothache.

[luchog]

If you're referring to L.'s husband, he had a transplant. He's currently back in the hospital, having just had an appendectomy. The anti-rejection drugs suppress his immune function so badly that he'll be prone to horrible infections for the rest of his life.
No, I didn't know that was an OD.

I'm referring to D. and his "cry for help" suicide attempt.

[deadrose]

No, I didn't know that was an OD.

I'm referring to D. and his "cry for help" suicide attempt.

Oh. I have no idea of the outcome of that one. He claims he's dying, but all in all, I'll believe it when I see the un-photoshopped medical documentation.

For that matter I'd want proof of the liver failure and not just a good stomach pumping.

It's a sad thing when so many people have cried wolf that you have to be suspicious of everyone's medical problems until proven by documentation (though in this case the suspicion is sadly deserved).

Heidi