Paracetemol - the hidden dangers

Paracetamol – that seemingly most innocuous of pain killers - is sold under various brand names such as Panadol and in the USA, Tylenol.

Almost everyone has some form of paracetamol in the house and most people take it at some time for all manner of issues – from colds and ‘flu to a hangover. It's the primary ingredient in the popular children's medicine, Calpol.

Paracetemol – along with various forms of non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen – is stocked by supermarkets, the corner dairy and petrol stations.  NZ is the only country in the world, other than the USA, in which pharmaceutical drugs are advertised on television – often by people who are presented as medical experts.

The fine print on a packet of 500 mg Panadol pills sold in New Zealand tells you that it’s safe to take up to 4 grams a day (eight pills) for 4 days at a time but, if symptoms persist, to consult a doctor. The fact that doctors in NZ frequently prescribe the maximum daily dose of paracetamol for 3 months at a time (720 pills) goes a long way to undermining the seriousness of that piece of advice from the manufacturers.

I don’t know the number of prescriptions for paracetamol written by doctors in NZ in a year, or how many paracetamol pills and remedies containing it are bought in over the counter annually but, according to an article in the Guardian, in the UK in 2013 doctors wrote 22.5 million prescriptions for it and around 200 million packets were sold over the counter – two-thirds of all the OTC painkillers sold. 

In the USA around 25 billion doses are sold annually.

It's a fairly safe bet that the majority of elderly people in New Zealand, especially those in rest homes, are on a persistent, maximum daily dose of the drug.

In the UK, a 2007 study found that 84% of babies are given Calpol in their first 6 months of life.

Paracetamol is the most widely prescribed and purchased analgesic in the world because it is very cheap and, compared to the dangers of long term use of the alternatives - steroids, non-steroidal anti-inflammatories (NSAIDs) and opiates, it’s considered to be fairly safe. 

But is it?

The National Institute for Health and Care Excellence (NICE) in the UK issued guidelines in 2013 urging doctors to review the prescription of paracetamol for osteo-arthritic pain but these were withdrawn after agitation from interested parties, notably the Royal College of General Practitioners.

The pharmacentric, symptomatic, pain elimination paradigm that most conventional health professionals are locked into, creates and maintains the patient expectation that, if you are ill or in discomfort, you are prescribed a drug. For doctors confronted with that well established expectation, paracetamol is the reliable old workhorse that they think they can put just about any patient on without fear of them being harmed.

The trouble is that the reliable old workhorse may not be the bullet proof, safe old nag its manufacturers claim and medical professionals believe it is.

Paracetamol causes more deaths world-wide from overdose than any other drug. It is the most common cause of poisoning in children in NZ and it is the single most common cause of acute liver failure in the USA, Australasia and Europe.  Five children a day are admitted to hospital in the UK suffering from paracetamol poisoning.

In overdose - the consumption of more than the recommended maximum adult daily dose  - it can be acutely hepatoxic. A paracetamol overdose that is not treated quickly enough to halt the production of the toxic metabolite NAPQ1, will result in liver damage and may result in acute liver failure and death.

It is also very easy to overdose as paracetamol is an ingredient in most flu and cold remedies, which may be taken at the same time as pills. It is a common cause of overdose in children because the medicines containing it are heavily sweetened and brightly coloured like confectionary.

For people with impaired liver function due to alcohol consumption, or genetic conditions like Gilbert’s Syndrome, or who are on certain barbiturates such as phenobarbitone, or who are malnourished, or have suffered  a recent illness - as little as 5 grams in a day can be acutely hepatoxic.

Even in therapeutic doses, people on long-term maximum doses of the drug suffer impaired liver function although there is no consensus on the clinical significance of this.  But, liver disease is frequently asymptomatic and even quite severe liver damage can be missed by physicians or attributed to factors other than paracetamol use.

IIn NZ the pills sold or prescribed for adult consumption are typically 500mg with no more than 4 grams to be ingested in a given 24 hour period.  In the USA, the recommended oral dose of the drug is 660-1000mg every 4-6 hours not to exceed 3 grams in a 24 hour period. The Food and Drug Agency (FDA) in the USA has also lowered the maximum pill dose to reduce risk of accidental overdoses. Although it is a small reduction given the amounts being prescribed and sold, it is in an indication that some health watchdogs are starting to wake up to the dangers posed by the ubiquity of the drug and the false perception that it is very safe. 

Whilst the toxicity of the drug in overdose is well documented, there’s not as much known about its effects in very long-term use at high doses. Given how many people with chronic pain are prescribed the drug at maximum dose persistently, this absence of data and the apparent lack of concern from health professionals is worrying.

A 2011 UK study concluded that 1 in 5 people who used paracetemol for chronic pain lost blood through internal bleeding, the same proportion of NSAID users in the study. Older people may be more sensitive to GI tract irritation because of a general thinning of tissue, so the fact that most older people in NZ with chronic pain are on long term maximum doses of paracetamol, is very worrying.

Also of concern, are studies that indicate the drug is not very effective at reducing musculo-skeletal pain. If this is the case, the gastro-intestinal, cardio-vascular, hepatic and renal risks make its widespread, long-term, high dose use for chronic musculo-skeletal pain, untenable.

All drugs have to be metabolised and all drugs have effects on the gastro-intestinal tract and the metabolic organs other than the desired effect. The problems associated with chronic high dose paracetamol use may be compounded by the fact that it is often used in conjunction with a range of other drugs. 

The more fragile the person, the more likely it is that there will be side effects and that those side effects may well outweigh any benefits of the drug. 

It’s also logical that, what is reckoned to be a safe dose of any given drug, is not a constant – it varies between individuals and any given person’s tolerance levels may change over time, and may change very quickly.

On the horrors of poaching

It's heartening that so many people are angry about the horrors of wild animal poaching in Africa and the utterly despicable 'sport' of trophy hunting.  There's little I find more revolting than those narcissistic, over-privileged pin-heads who travel to Africa to kill virtually captive animals for what they deem to be 'sport'. 

The idea of killing elephants for their ivory or rhinos for their 'horn' or any other example of monstrously wasteful, cruel slaughter of other species fills me with grief and rage. 

So, I'm supportive of animal rights activism and kudos to Ricky Gervais who has been a powerful influence via social media in taking a stand against these monstrous activities.

However, I do get disturbed by the incessant flow of graphic images of extreme human cruelty against animals. I acknowledge that such images raise awareness of, and anger about the appalling destruction of the world's wild life - and the millions of domestic victims as well - but they do little to expose the roots of the matter and they don't help people to an understanding of what actually needs to be done to stop it. 

A while back Ricky Gervais tweeted a photo of what he described as a  'poacher hunter' - a heavily tattooed, muscular young woman toting an assault rifle almost as big as her.  

People, whose individual footprint on the planet is probably many times that of an entire African village, whooped with delight at the idea of the foot soldiers of the world's most destructive and wasteful empire using their martial skills and technology to 'hunt' African poachers. 

They seemed unaware of the irony in the fact that a lot of the poachers these Americans are said to be 'hunting' are poor Africans who illegally hunt elephants and rhino to feed the fetishistic desires and obsessions of very rich, non-Africans. 

As it happens, the decorated ex-soldier turned 'poacher-hunter' who got some folk on Twitter all aflutter is actually an ex-US army diesel mechanic turned model for American arms manufacturers and traders. The photo was from a series of shots promoting guns and associated military and para-military accoutrements. 

The organisation she now works for is a charity set up by an American ex-soldier to deploy other US army veterans to protect African wild life by training local rangers.  So, Kinessa Johns and her colleagues are not 'poacher hunters' but 'ranger trainers' which doesn't have quite the same bush cred.

The charity also claims that the activity helps those ex-soldiers who have PTSD developed when serving American global interests in Afghanistan and Iraq.

I'm surely not alone in seeing the irony in psychologically damaged working class, white, surplus to requirements defenders of global American interests taking their people hunting skills and hardware to Africa to train some Africans to defend some African wild life against other Africans. 

Before Europeans enslaved millions of Africans and colonised and divided up the entire continent to suit their imperial ambitions, Africa's diverse peoples lived in relative harmony with all those species that we, in the developed world, now get emotional and sentimental about.  

People from the first world were the enslavers, the colonisers, the collectors, the exploiters and the habitat destroyers. They were, and still are, the trophy hunters. It is mostly wealthy white people who own and manage the wildlife farms where wealthy white inadequates can pay to shoot captive big game. 

We in the developed world, as the inheritors of the wealth and privilege of empire, have a very different relationship to the wild life of Africa from that of  the peoples who were subjugated by empire. 

People from the first world, having killed off much of their own indigenous wildlife and - in pursuit of imperial ambition destroyed vast swathes of the habitat of third world animals - now want to dictate to third world people how they should manage those animals which remain. 

Of course, we in the developed world, having learned from our masters' appalling mistakes, need to take immediate action to stop other countries from repeating them. 

But a disturbing number of people look at the damaged and depleted world their political and economic masters have created and conclude that the problem is there are too many humans and they are destroying animals and their habitats. 

The corollary for them is that, to protect the animals, we need fewer humans. No prizes for guessing where those humans deemed to be surplus to requirements mostly live and what social class they occupy.

When Gervais suggests to his followers on Twitter that Chinese men need to be told 'poachers' teeth' are a better virility enhancer than rhino horn, he's not only taking the easy route, he risks tapping into a deep vein of racism. 

The developed world grew rich and powerful by sucking the life blood out of Africa and today, the developed world - including its new manufacturing heart, China - is still sucking the life blood out of it.  

What Gervais and others need to get to grips with is the fact that, if we really want to bring about change, we need an equally furious and wide spread condemnation of the developed world's continued exploitation of Africa's agricultural, mineral and oil wealth.

We need equally powerful demands - of governments and corporations - that Africans be allowed to manage their own resources, to invest the revenue from them in viable communities, food production, health care, education, housing and jobs instead of the bulk of the wealth being siphoned off by first world transnational corporations and the reactionary and corrupt domestic elites those corporations help keep in power.

Sentiment over endangered animals needs to be balanced by sentiment over impoverished humans - and the common root for these linked evils needs to be exposed. That is not easy but, if we are to put a stop to the plunder of this finite world, it has to be done.

A good start point is to look at how our own prodigal life styles, aspirations and expectations help determine the fate of these animals.