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The National Institute of Alcohol Abuse and Alcoholism notes that liver damage may occur with as little as 2.6 grams of acetaminophen (four to five "extra-strength" pills) taken over the course of the day in persons consuming varying amounts of alcohol (NIAAA, Seeff). The damage caused by alcohol-acetaminophen interaction is more likely to occur when acetaminophen is taken after, rather than before, the alcohol has been metabolized.
This liver damage is so serious it leads to the need for liver transplants. Since 1998, the Food and Drug Administration in the United States has required a specific warning on labels about acetaminophen. That warning reads:
• Acetaminophen: "Alcohol Warning: If you consume 3 or more alcoholic drinks every day, ask your doctor whether you should take acetaminophen or other pain relievers/fever reducers. Acetaminophen may cause liver damage."