IV Tylenol As Good As Moose Urine For Post-Op Pain Control

OK, I may have taken some license with the title but not with the science. Here's the real title of a November 2019 paper in Pain Medicine News: 'Post-op Pain Unaffected by IV Acetaminophen After Minimally Invasive Spine Surgery." I prefer mine.

This is hardly the first time I have jumped ugly on Tylenol (acetaminophen). Aside from reducing children's fevers and maybe working synergistically with Advil, there is no evidence that it is effective for treating any kind of pain (See Tylenol Isn't So Safe, But At Least It Works, Right?) and plenty of evidence that it does nothing at all. 

What's that part about it not being so safe? ACSH friend Dr. Aric Hausknect, a New York neurologist and pain management specialist suggests this in a not-so-subtle way. 

"Tylenol is by far the most dangerous drug ever made."

Pain In The Time Of Opioid Denial: An Interview With Aric Hausknecht, M.D. 7/30/17

Yet, despite overwhelming evidence that Tylenol (acetaminophen) is an abject failure as a pain drug, hospitals and physicians, who are desperate to avoid opioid use no matter the circumstances, keep shoveling it into the mouths and veins of Americans. Just one of the many instances of medical insanity brought about by ignorant (or self-serving, you pick) edicts forced upon us by PROP (with generous help from "Clueless Tom" Frieden's CDC) beginning roughly a decade ago. 

Speaking of PROP, don't you think it's time that they got a new image? These guys are all over the news and it's getting stale. They need to re-brand. Here, I'll help.

Original image: Iranian.com

Back to the Tylenol.

Let's take a look at what we already know – that giving Tylenol for pain is a waste of the water it takes to swallow the pills and that giving it IV during or after surgery is ideologically-driven stupidity. 

“Although previous literature supports the benefit of including multimodal analgesia as part of an intraoperative pain management plan, our results failed to identify a measurable effect of perioperative acetaminophen alone on opioid requirements or pain scores." 

Eugenia Ayrian, M.D., Keck School of Medicine of the University of Southern California 

Here are two non-surprises: 1) Tylenol doesn't work; 2) When you see the term "multimodal" there's a pretty good chance that you can substitute "a whole bunch of other crap that doesn't work" and not be far off the mark.

“While intravenous acetaminophen may benefit a carefully selected subset of patients undergoing surgery, prospective carefully standardized studies need to be done to determine which patients will have the greatest benefit.”  (Also from Dr. Ayrian)

"Carefully selected subset?" Why does the following image come to mind? 

Photo: US Air Force Academy

According to the article, Dr. Ayrian and colleagues initiated a prospective randomized trial (first-rate) which somehow turned into a retrospective study (anything but first-rate) – no small feat. How did this happen? Prepare yourself.

The trial (187 patients) was supposed to compare pain levels of patients who underwent "minimally invasive" spinal surgery, for example, a discectomy, where the damaged part of a herniated or bulging disk is removed. Three groups were randomized: IV acetaminophen, oral acetaminophen, or neither. Then this happened (emphasis mine):

"However, due to the high cost of IV acetaminophen, a shortage of remifentanil and the disapproval of the research committee, the trial was stopped before completion."

Do you see any problems here?

1. The hospital can't afford enough IV Tylenol for ~60 patients?? It costs 40 bucks for a 1,000 mg bottle. 
2. They ran out of remifentanil, which, like fentanyl is used to maintain general anesthesia. What are they using instead? 

Is this the Keck School OR? Image: Viralnova.com

3. I don't know what they did to piss off the research committee but it must have been a doozie. This does not happen often.

Which gives me a chance to simultaneously endorse a really good movie while voicing some mild reservations about the hospital in question:

Ford vs Ferrari - excellent!   Keck School of Medicine - maybe not so much. Now we know why they were driving so fast.

HOW WELL DID THE IV TYLENOL WORK?

It didn't.

Data from the paper is presented in graph form. Different dose forms, time intervals... doesn't matter. It made no difference whether surgical patients got Tylenol. None.

HOW WELL DOES MOOSE URINE WORK?

For those of you who are on the edge of your seats waiting to see the moose urine data, I must report with great sadness that, like the Keck School, we too suffered from logistical problems. In our case, it was a supply shortage. Estelle wasn't up to the task.

Photo credit: Flickr