Inscribed on a 6,000-year-old clay tablet, you'll find the ancient origins of a turn-of-the-century miracle drug: Aspirin. The tablet's authors knew that ingesting willow bark relieved pain and discomfort. Little did they know their discovery would remain popular many millennia later.
Today, a bottle of 100-count aspirin costs less than $2, and relief from fever, aches and pains is only a pill or two away, much easier than preparing a hot cup of tree bark tea. What's more, all it takes is a stroll down the pain relief aisle to notice aspirin's got lots of company.
Medicines like ibuprofen, naproxen and acetaminophen — marketed under a variety of brand names — have greatly expanded our options. But, ironically, they've made picking the best one something of a headache itself.
Does one work better than others? And is there a right and wrong choice based on one's health?
Yes, says Dr. Sreedhar Gottiparthy, a primary care physician at Houston Methodist, who helps explain the risks and benefits of over-the-counter (OTC) pain medications.
"Pain is any unpleasant sensation with many different levels and feelings, and no two people experience pain the same way," says Dr. Gottiparthy. "Many people take what they know from friends and family and advertisements they may have seen. But taking too many of one type or the wrong type based on their condition can cause significant side effects."
In a world where everybody hurts from time to time, it's important to know what your relief options are and what might do more harm than good in certain circumstances.
Comparing common OTC pain relievers
OTC pain relievers, also known as analgesics, are those medicines you can get without a prescription. You might be surprised to hear that literally hundreds of OTC medicines — including many cold and flu medications — contain at least one pain-relieving agent.
But despite how many OTC medications contain pain-relieving ingredients, there are really only three main categories: Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and lidocaine.
Acetaminophen: Benefits, uses and side effects
Acetaminophen, which helps relieve pain and reduces fever, is the medication Dr. Gottiparthy recommends most people start with when taking OTC pain medicine. (It is called paracetamol in many other countries.)
"It's generally a good idea to start with something like acetaminophen, which has fewer side effects on the stomach and kidneys than NSAIDs might," says Dr. Gottiparthy. "In fact, anyone who is planning to take NSAIDs for the first time for pain instead of acetaminophen should touch base with their physician to make sure that it's safe for them to take, even for a short period of time."
When it comes to acetaminophen, the line between maximum pain relief and liver failure is thinner than one might think, with acetaminophen overdose a common cause of acute liver failure in the U.S. People with liver problems or on the blood thinner warfarin likely should not take acetaminophen.
Dr. Gottiparthy says not to exceed 4,000 milligrams — the equivalent of eight extra-strength tablets — in 24 hours. If your doctor recommends a prescription medication, he adds, let them know what OTC medication you're taking.
"It's a good idea to talk about all of the over-the-counter medications, irrespective of what those are, to your physician," says Dr. Gottiparthy. "People experiencing pain might be taking acetaminophen, and the provider might give them a medication that has acetaminophen on top of it that might exceed the daily recommended dose."
NSAIDs: Benefits, uses and side effects
NSAIDs work by blocking specific enzymes that cause inflammation, pain and fever. Within the category of NSAIDs, only three are available OTC: Aspirin, ibuprofen and naproxen.
Aspirin calls for special attention if taking
"It's surprising many people don't know not to take multiple tablets or higher doses at a time," says Dr. Gottiparthy. Specifically, the FDA recommends doses should not be more than 650 mg every four hours or 975 mg every six hours — in other words, no more than two regular-strength tablets every four hours and no more than two-extra strength tablets every six hours.
The amount is important because, unlike ibuprofen and naproxen, aspirin presents one problem the others don't: irreversible overdosing. Because of the way aspirin breaks down, there isn't a way to undo the effect of taking too much.
If you think you've taken too much aspirin, do not self-medicate. Call poison control, dial 911 or seek immediate medical care. You'll likely get activated charcoal, which prevents aspirin's absorption — and thus minimizes the damage from overdosing.
Aspirin's effects are dose dependent. Larger aspirin doses are used for its pain-relieving, anti-inflammatory and fever-reducing effects, whereas low doses (81 mg tablets also known as "baby aspirin") are used long-term in certain patients to prevent heart attacks and strokes. This creates an antiplatelet effect, which decreases your body's ability to form blood clots.
While all NSAIDs present possible gastrointestinal side effects, it is aspirin's antiplatelet effect that poses more risk to gastrointestinal bleeding than others.
Ibuprofen and naproxen may have fewer side effects than aspirin
Although ibuprofen and naproxen may present fewer overall side effects than aspirin, they still carry the common side effects associated with NSAIDs, according to Dr. Gottiparthy.
"Taking a lot of ibuprofen or naproxen for an extended period of time without knowing the root cause of pain can expose you to a lot of the side effects associated with NSAIDs," says Dr. Gottiparthy. "Impaired kidney function, gastritis and gastrointestinal bleeding could all still occur."
"The 'not to exceed' label on the side of the medication bottle is very important to follow," says Dr. Gottiparthy, "but duration also is worth mentioning because these medicines shouldn't be taken for too long."
Be careful of NSAIDs and blood pressure medication interactions
According to Dr. Gottiparthy, people who take certain blood pressure medications should be especially cautious of taking NSAIDs.
"People with blood pressure or kidney problems should not take NSAIDs without talking to their doctor about their medications," says Dr. Gottiparthy. "NSAIDs can interact with diuretics, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) and can cause a decrease in kidney function even in small doses."
If people don't disclose the over-the-counter medications they're taking, NSAIDs can be part of an unintentional triple whammy — a dangerous combination of NSAIDs, ACE inhibitors or ARBs, and diuretics that can lead to kidney failure.
"Even taking just two out of the three medications can be harmful," says Dr. Gottiparthy. "It's even more difficult because it's not really dose-dependent, so even small doses of NSAIDs aren't safe to take with this combination unless your physician suggests."
"Even if you've recently taken an NSAID just once for a headache or another short-term treatment, it's a good idea to inform your physician," says. Dr Gottiparthy.
Dr. Gottiparthy suggests sticking to acetaminophen if possible.
Lidocaine: A different kind of relief worth considering
If you've got sore muscles, backaches or arthritic joints, lidocaine might be worth considering over popping a pill or two. As a local anesthetic, lidocaine can be applied topically and works by blocking pain signals being sent to your brain and works differently than acetaminophen and NSAIDs do, which can be a great benefit, says Dr. Gottiparthy.
"Lidocaine is a very helpful pain reliever especially in people who are elderly or who take multiple medications," says Dr. Gottiparthy. "It not only helps reduce the number of medications that somebody has to take orally, but it can also be an alternative to NSAIDs for people who experience gastrointestinal side effects."
"So in combination or on its own," says Dr. Gottiparthy, "lidocaine is great help, actually."
Lidocaine comes in a gel form or via a patch that you can apply to the area where you're experiencing pain.
Medications can be combined, but be careful
So, what happens if you combine a little bit of this and a little bit of that? The answer: You can combine medications, but you should be careful of what you combine, says Dr. Gottiparthy.
"Acetaminophen and ibuprofen or naproxen have been combined for quite some time actually, and in certain countries they manufacture this combination medication," says Dr. Gottiparthy. "But I don't often suggest it, and thankfully not many people take it."
Instead, if a patient's fever or discomfort continues after taking acetaminophen, they can then take an NSAID like ibuprofen or naproxen, according to Dr. Gottiparthy. Just be sure to take it a few hours out from the first dose, he adds.
"Many patients are aware they should not be taking too many of any one medication," says Dr. Gottiparthy. "That's one of the reasons why they take both, an acetaminophen and an NSAID like ibuprofen or naproxen."
Avoid combining OTC NSAIDs
While acetaminophen can be combined with NSAIDs like ibuprofen and naproxen, combining two over-the-counter NSAIDs like aspirin and ibuprofen should be avoided, says Dr. Gottiparthy. Not only will some combinations reduce the efficacy of one or both medicines, but they can also increase the chance of gastric irritation or bleeding.
Name brands don't matter — that much
It's hard to avoid saying name brands when talking about OTC pain relievers. After all, Tylenol rolls of the tongue much easier than, say, acetaminophen or paracetamol.
For questions about name brands versus generics, Dr. Gottiparthy offers up the world of automobiles.
"Is it OK to drive a Toyota Camry or should everyone go for a Lexus?" asks Dr. Gottiparthy. "The answer is both. Their purpose is the same. It comes down to how much you can afford and what kind of mental state you are in to believe that the generics work."
"The generic versions of these medications are not inferior," says Dr. Gottiparthy. "As long as you are in a country where the standards of medicine are maintained very well, it's difficult to release low-quality items into the market."
The FDA makes it clear: Generic medicines work the same as brand-name medicines. They are required to be the same in dosage, safety, effectiveness, strength, stability, quality, and in the way it's taken.
That said, it's helpful to remember what analgesics name brands contain:
- Tylenol contains acetaminophen
- Advil and Motrin contain ibuprofen
- Aleve and Naprosyn contain naproxen
- Bayer contains aspirin
When pain relief goes behind the counter
The options discussed thus far deal with non-prescription pain relief for short-term ailments. But when is a prescription appropriate or needed for pain relief?
Interestingly enough, the same ancient peoples who discovered willow bark as the precursor to aspirin made another interesting finding: The red flowering plant we know today as poppy contains a powerful pain reliever, opium, known today as a highly addictive narcotic. Thankfully, modern medicine today affords many different options when it comes to treating pain and its causes.
"Treatment will depend on the type of pain, its source, the intensity, the patient's medical conditions, and how long we plan on treating it," says Dr. Gottiparthy. "Nerve pain, for example, may not involve any narcotic or prescription NSAID. We typically use medicines like gabapentin and pregabalin in these cases."
Back pain, elbow pain, headaches, and nerve pain are all examples of recurring discomforts that a patient may want to seek treatment for, says Dr. Gottiparthy.
"If a patient experiences pain more than a couple of times in the same place," says Dr. Gottiparthy. "It's a good idea to have it investigated by a physician, even if temporarily relieved by OTC pain medications."
