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Tylenol 3 & 4 Abuse and Addiction

Isaac Alexis, M.D., AAMA, AMP-BC

Medically reviewed by

Isaac Alexis, M.D., AAMA, AMP-BC

January 17, 2019

Tylenol 3 and 4 are prescription painkillers that should be treated with caution and responsibility. These drugs are more potent than over the counter Tylenol as they are a combination of acetaminophen and codeine and have a higher potential for abuse and addiction. It is important to know how these medications work so they can be taken responsibly.

What Is The Difference Between Tylenol 3 And 4?

Tylenol 3 and 4 are very similar drugs, in the capacity that they both contain the same active ingredients and are considered to be within the class of narcotic analgesic combination drugs. The difference is the proportion of codeine to acetaminophen. While the amount of acetaminophen is constant in both preparations (300 mg per dose), the amount of codeine doubles from one medication to the next; thus, the potential for abuse rises. Tylenol 3 contains 30 mg of codeine, whereas Tylenol 4 contains 60 mg.

Acetaminophen is the active ingredient in all Tylenol, and is used as a pain reliever and an antipyretic (fever reducer); standing alone, this is a fairly mild painkiller that is used for low to moderate concerns of pain. Codeine is also used for the treatment of mild to moderate pain, and in certain cases (typically in combination with another drug), as an antitussive (medication for coughing).

Together, these drugs yet treat mild to moderate pain, such as that associated with osteoarthritis, intense headache, dental concerns, severe PMS, or pain after an operation. These drugs are recommended for short-term use, and not for long-term management of chronic pain, due to the increased risk of adverse effects.

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Side Effects Of Tylenol 3 And 4

These drugs may cause a person to be dizzy or lightheaded, or experience dry mouth, nausea, vomiting, or constipation. In rare cases, or in patterns of abuse, these drugs may cause confusion, agitation, strange behaviors, mood changes, hallucinations, difficult and slowed breathing, decreased heart rate, and seizure. Symptoms of overdose may be heavily dependent on which of the two active ingredients are predominantly responsible for the overdose, and will be discussed in greater detail in the following sections.

Surprisingly, overdose and death may, in some cases, arise sooner from the acetaminophen, than the codeine. This is because it is present in higher amounts per dose, thus, in situations of abuse, a person may reach the toxic threshold for this drug sooner than they would for codeine.

Is Tylenol With Codeine Addictive?

Certain individuals may choose to use these drugs for recreational purposes, seeking the sense of relaxation and euphoria that the codeine may produce when used in amounts greater than prescribed. In comparison to other opioid drugs, codeine is a weaker Mu agonist, and only ten percent is metabolized to morphine.

Codeine may not be the strongest opioid medication, but it’s still an opioid, and it carries a risk of serious health effects, abuse, and addiction. Abusing codeine not only increases the risk of addiction, it also increases the risk of overdose.

As a person uses codeine in increased doses and frequency, they may develop a tolerance, and begin taking more of the drug. If they use too much of the drug, a person may overdose from codeine in Tylenol 3 or 4; similar to other opioids, symptoms of this may include:

  • trouble breathing
  • decreased heartbeat
  • dizziness
  • extreme drowsiness or fainting
  • becoming unconscious
  • skin becomes cold and clammy

An overdose is a serious situation, and needs to be treated as such. Contact medical help immediately in the case of any opioid overdose situation. Even if there’s a fear of legal repercussions, calling 911 can save a person’s life.

Opioid Withdrawal Symptoms

Even in prescribed settings, codeine-containing drugs may be habit-forming, due to a physical dependence that could occur from prescribed use. Because of this (or in instances of addiction), withdrawal symptoms may occur should you suddenly stop using the drug, such as:

  • restlessness
  • anxiety
  • yawning
  • sweating
  • chills
  • teary eyes and runny nose
  • decreased appetite
  • insomnia
  • muscle or backache
  • nausea
  • vomiting
  • diarrhea

It can be risky to quit opioids “cold turkey.” A medically-supervised detoxification is the safest, and most effective way to treat opioid withdrawals.

Dangers Of Acetaminophen

Due to the widespread presence and application of this drug, many individuals may dangerously think that it is fairly benign. Despite the fact that acetaminophen alone (also referred to as paracetamol) is an over-the-counter drug, this does not mean that it is without risks. On the contrary, acetaminophen is implicated in a number of very serious, and even deadly, conditions—adverse effects that are not only present, but magnified, with Tylenol 3 and 4 use and abuse.

Researchers found that the most common cause of acute liver failure in the United States is due to excess amounts of acetaminophen. An individual should not exceed 4000 mg (or 4 grams) of acetaminophen per day—considering that research suggests anything over this amount is considered an overdose, and as little as 7 to 7.5 grams a day could be severely toxic, there is little room for misuse.

Research published by the British Journal of Clinical Pharmacology (BJCP) in early 2012 shed light on another pertinent concern associated with acetaminophen—overdose. Though overdose is widely thought to be a situation that quickly rises from one-time use, it is possible that it occurs more slowly, over time, in a manner that is sometimes referred to as a “staggered overdose.”

When this occurs, instead of a person taking too much of a drug too fast, in one setting (what the study refers to as a single time point overdose), an individual instead takes numerous smaller doses over time, including amounts that are even just slightly above the recommended dose. What happens is that the drug’s effects build up, accumulating a toxic potential and increasing a person’s risk of hepatotoxicity, or chemically-induced liver damage. In the gravest of cases, this damage may be so severe that a person dies, most often to acute liver failure.

“Despite lower total ingested paracetamol doses…staggered overdose patients were more likely to be encephalopathic on admission, require renal replacement therapy or mechanical ventilation and had higher mortality rates compared with single time point overdoses.” These staggered overdoses resulted in fatalities in 37.3 percent of admissions, versus the 27.8 percent witnessed for single time point overdose.

What this means is, while patterns of staggered overdose may actually result in a smaller, total amount ingested, when compared to that of single time point overdose, the risk is, in many ways, greater. The publication continues, noting that staggered overdose was correlated to multi-organ failure and situations that required emergency orthoptopic liver transplantation.

Mercola puts it into perspective, outlining that an individual would be at risk of liver damage after only a couple weeks, if they consumed each day only 25 percent more than the maximum daily dose. This site also notes that if an individual were to take just below four times the maximum daily dose, at one time, they would be consuming a lethal dose. These findings are worrisome, as individuals who choose to self-medicate or abuse Tylenol 3 or 4, would then be consuming an excess amount of acetaminophen over time, thus creating risk of these effects, coupled also with the effects of increased codeine.

What is troublesome about acetaminophen overdose, is that some people don’t exhibit signs, or exhibit few before returning to a seemingly normal state. For this reason, many overdose states go unnoticed and do not receive the appropriate care in time. Signs of acetaminophen toxicity include, according to Medscape, nausea and vomiting for the duration, and also in:

Phase One:

  • anorexia
  • paleness
  • fatigue
  • general state of feeling poorly

Phase Two: At 18 hours to three days

  • stomach pain located in the upper quadrant
  • tachycardia (rapid heartbeat) and hypotension (low blood pressure)
  • possible decreased output of urine

Phase Three: At three to four days

  • continued abdominal pain
  • tenderness at the site of the liver
  • “hepatic necrosis and dysfunction may manifest as jaundice, coagulopathy, hypoglycemia, and hepatic encephalopathy”
  • some develop acute renal (kidney) failure
  • possible fatality due to multiorgan failure

The good news is, Medscape notes that in Phase Four, “Patients who survive critical illness in phase 3 have complete resolution of symptoms and complete resolution of organ failure.” Keep in mind, this is in regard to only acetaminophen, total effects and damage may be altered by the codeine. In addition, in the case of a single time point overdose, if medical attention is sought within the first 12-16 hours, a medication called N-acetylcysteine may be administered to prevent liver injury.

Dangers Of Mixing Opioids With Other Drugs

As with many medications and every drug of abuse, the risk of adverse side effects increases when these drugs are used adjunct with other medications or drugs. Polysubstance abuse is quite common within recreational drug users, in an attempt to heighten the pleasurable or euphoric state they seek. Two drugs hold specific concerns in regard to Tylenol 3 and 4—benzodiazepines and alcohol—creating hazardous, and even deadly, results.

Benzodiazepine drugs are a class of psychoactive sedative medications including Valium, Ativan, and Xanax. Late this summer, the FDA issued a news release, requiring their strongest warning, boxed warnings, for opioid analgesics and benzodiazepines both, due to the “serious risks and death from combined use.” This is because both of these drug types have the capacity to render serious effects from the impact to the central nervous system (CNS). The FDA elaborates, stating “Risks include extreme sleepiness, respiratory depression, coma and death.” Any combined use of these drugs can be worrisome, however, the larger quantities of drugs that are commonly used in situations of abuse have even greater potential for these dangers.

Alcohol poses numerous threats, the predominant risk being that of serious, and even life-threatening liver damage; however, there are other risks that occur when these drugs are used concurrently, or even within the same period of time. Alcohol takes a massive toll on your liver, and as we’ve discussed, acetaminophen holds the potential to do the same. Together, these drugs could exert a toxic force, leading to increased risk and instances of hepatotoxicity and acute liver failure.

Alcohol impacts another important organ—the kidneys, and research also illustrates that acetaminophen may also cause detriment to these organs. In 2013, new research illustrating the combined effects of these drugs was presented at the American Public Health Association’s annual meeting. The findings were surprising and documented “Results from the study indicated that neither taking a therapeutic amount of acetaminophen nor consuming a light to moderate amount of alcohol posed a particularly greater risk to an individual’s kidneys. However, when taken in combination with one another, results showed a 123 percent increase in risk of kidney dysfunction.” Due to these heightened risk, experts recommend individuals who consume three or more alcoholic drinks per day to refrain from taking drugs containing acetaminophen.

In addition, various other prescription drugs may interact with Tylenol 3 or 4, in a way that could be problematic or harmful. For this reason, it is imperative that you communicate to your doctor any and all other medications or supplements you may be using, including over-the-counter, prescription, and illicit, in order to circumvent additional risk.

Find The Best Opioid Addiction Treatment For You

Have you begun misusing pain medications? Are you fearful that this behavior is verging on abuse or addiction? Or perhaps you’ve already found yourself in these harmful situations. If you’re concerned about pain management but are struggling with prescription painkiller abuse or addiction, can help you to examine your options and find viable treatment options. Contact us today.

New York State Office of Alcoholism and Substance Abuse Services - Opiates Workbook

US Food and Drug Administration - FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use

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