I keep thinking back ten years ago when I asked my doctor which painkiller she would recommend for those of us with liver disease. Her reply was “none of them.” I remember that I was surprised and thought she was being a bit radical, but as time goes by and I research the topic, her abrupt answer is turning out to be prophetic.

In 2004, COX-2 drugs, such as Vioxx®, were withdrawn after research showed participants taking the drugs had higher rates of heart attacks than those not taking it.

In 2005, the FDA investigated NSAIDs (non-steroidal anti-inflammatory drugs) and manufacturers were asked to revise their labels to include warnings of increased risk of cardiovascular disease, stomach bleeding and skin reactions. They are especially worrisome for those of us who are on SSRI antidepressants and/or have cirrhosis because they increase the possibility of esophageal bleeding.

In 2006, Dr. William M. Lee, University of Texas, announced at the national Digestive Disease Week meeting that acetaminophen has a rather narrow safety window; even therapeutic doses can cause toxicity. “It can be a second insult to the liver cells on top of hepatitis,” said Dr. Lee since acetaminophen overdose is now the most common cause of acute liver failure. According to Dr. Lee, “Unbundling of painkillers would be significant in terms of reducing accidental overdose,” since acetaminophen and NSAIDs are “bundled” in hundreds of products, causing people to unwittingly take too much. Acetaminophen, for instance, is in prescription meds such as Vicodin and Percocet, which are the two most popular prescription drugs for pain relief in people with liver disease, and in many over-the-counter remedies. So if an HBV patient is taking, say, Extra Strength Tylenol for interferon side effects, Midrin for a migraine, and Nyquil for insomnia, he is probably accumulating toxic amounts of bundled acetaminophen.

Hepatitis B isn’t usually considered a particularly “painful” disease. My HBV friends may report joint pain, interferon treatment discomfort, and side aches, but those with severe debilitating pain usually suffer from another chronic disease, such as arthritis or fibromyalgia.

An answer to our dilemma might be to rethink the use of narcotic painkillers for chronic pain. Unfortunately, I’ve found that it’s difficult to have an objective conversation about the benefits of these medications. But according to some experts, narcotics may be safer than many people think; they are not associated with any organ damage to the liver, kidney, heart, or lungs.

“There’s this myth that if you take an opiate [narcotic], you automatically become enslaved to it,” writes Dr. Karen Miotto, an addiction psychiatrist at UCLA, for the website WebMD. “But that’s not the case. For the relatively small number of people who do develop a prescription drug addiction, the effects can be devastating, but the majority of people who use them are using them responsibly.”

Best wishes,

Steve