We all get various aches and pains, whether they be headaches, joint pain, backaches or the generalized achiness that goes with many viral illnesses. When we do, we typically reach for something to relieve the pain. These days we are all-too-aware of the problems with narcotics, the most potent pain relievers, and doctors are much more reluctant to prescribe them. There are a lot of non-narcotic alternatives, most of which can be bought off the drugstore shelves without a prescription. Most of these are safe when used in low doses for a short time, but they are not “safe” in the sense that they can be taken at will.
Most non-prescription pain relievers are NSAIDs, non-steroidal anti-inflammatory drugs. These relieve pain by reducing inflammation. The class includes many prescription medications and two widely-available drugs, ibuprofen (Motrin) and naproxen (Aleve). The grand-daddy of all NSAIDs, of course, is aspirin. The most common pain reliever that is not an NSAID is acetaminophen (Tylenol).
NSAIDs reduce inflammation by inhibiting the body’s production of the hormone prostaglandin. While this has the good effect of reducing pain and inflammation, prostaglandin has many other roles in the body. Notably, it protects the stomach by building up the lining, and it helps regulate blood flow to the kidney. Hence, taking large doses of NSAIDs for an extended period can lead to gastritis or ulcers and can result in serious stomach bleeding. This is often made worse because aspirin and all NSAIDs decrease the ability of platelets to stick together and stop bleeding. Particularly in older patients or those with reduced kidney function, but possible in any person, NSAIDs can cause worsening kidney function, which can become permanent if not caught early. A just-published study of young healthy adults (U.S. soldiers) found that even among these low-risk folks, regular use of NSAIDs was linked to acute and chronic kidney disease. Because of their effect on platelets, NSAIDs are particularly hazardous to patients taking blood thinners.
OK, then, I guess it is acetaminophen, right? Used properly, acetaminophen is remarkably free of side effects. However, when used too much, it has its own problem: liver damage. The recommended safe dose of acetaminophen is 3 grams (3000 mg) per day in healthy people. This is the amount found in six “Extra strength Tylenol.” When healthy volunteers took 4 grams/day for a week, three quarters (76%) developed at least mild elevations of their liver tests. Single doses of over 7.5 grams (usually over 15 grams) can cause severe damage to the liver, often irreversible, and acetaminophen overdose is the commonest cause of severe acute liver failure. A key consideration is that acetaminophen is found in many prescription (Percocet, Vicodin, Fioricet) and non-prescription (Tylenol-PM, Actifed, etc.) medications, so be sure to read the label of any pills you are taking. Another important warning is that if you drink alcohol, this is already adversely affecting your liver, so it will be more sensitive to the effects of acetaminophen.
What is one to do? First, the safest option for pain is often non-medication: ice, heat, stretches, massage. If these do not work, acetaminophen in safe doses is the next to try. If you are young and otherwise healthy, up to 3 grams/day. If you drink, keep it to 2 grams/day. Be sure you are not already getting some in other pills you are taking.
If acetaminophen does not work, and it often does not for joint pain, then ibuprofen or naproxen are the next step. This are very similar in effectiveness, though some people get better relief from one than the other. The major difference is in how long they work; ibuprofen typically works for 4 to 6 hours, while naproxen works for 8-12 hours. If you can get by with taking these in the label-recommended dose for a few days, they are generally safe. If you need to take them for a long time, ask your doctor about the need to have your kidney function monitored and/or the advisability of taking medication to protect your stomach.
And remember to try non-medication approaches along with any pills you take!
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