Patient Education

Over the Counter Pain Relievers

Over the counter pain relievers are sold under many different names and they are divided into two categories. The first category is that of the non-steroidal anti-inflammatory medications (known as NSAIDs) with such examples as Aspirin, Advil, and Aleve. The second category is the centrally acting analgesics, the most popular being Tylenol .

These medications are available in the generic form and sold side by side with their name brand counterparts. Aspirin is sold by its name and is available in a buffered or enteric coated form to protect the stomach. Advil and Motrin are perhaps the best- known names associated with their generic equivalent ibuprofen. Aleve's generic equivalent is naproxen. Tylenol and Anacin are the name brands for acetaminophen.

How do these medications work?

The NSAIDs work by blocking the creation of an enzyme in the body that incites inflammation known as cyclo-oxygenase (Cox). In so doing, they also block the creation of a chemical that protects the stomach and the kidneys. Because the aforementioned NSAIDS are non-selective, much research has been performed to find an NSAID that blocks only inflammation without the risk of stomach ulcers and raising blood pressure. Vioxx, Celebrex and Bextra were supposed to be those drugs as they are designed to block only the enzyme that mediates inflammation. Vioxx and Bextra have since been recalled leaving Celebrex as the only FDA approved COX 2 selective NSAID.

While it is not well understood, acetaminophen works not by blocking inflammation but by interacting with the same pain receptors in the brain that morphine and its' relatives use.

How should these medications be taken?

All over the counter pain medications should be used for pain that is relatively new (aka acute) and should not be taken for more than a few days to a week unless otherwise directed by a physician. The NSAIDs should always be taken with food or a glass of milk to coat the stomach as they can cause nausea or even a bleeding ulcer. One should not be taking two different NSAIDs at the same time.

Naproxen may be taken two at a time up to twice a day, approximating the prescription strength of Naprosyn.

Ibuprofen may be taken up to four pills three times per day, approximating the prescription strength of Motrin.

The above dosages are only necessary to achieve the anti-inflammatory effect, but the pain-relieving effect can be achieved at the low dose prescribed on the bottle.

Acetaminophen may be taken on an empty stomach as it rarely causes gastrointestinal upset. One should not exceed 4000 mg per day of Tylenol (i.e. no more than 8 extra strength tablets) because of the potential deleterious effects on the liver.

Can everyone use these medications?

These over the counter pain relievers may not be appropriate for everyone. While allergic reactions to these medications are rare, they can happen. Symptoms of a rash, itching, shortness of breath and swelling of the lips and tongue are just a few of the symptoms and should prompt a call to your family doctor or a visit to the Emergency Room. Those with a true allergy to Aspirin should avoid the entire class of NSAIDS.

Blood in the stool, dark black stools, abdominal discomfort, nausea or lack of appetite may be the symptoms of an ulcer or internal bleeding and the medications should be discontinued.

You should consult with your primary doctor regarding use of the NSAIDS when already taking blood thinners such as plavix, coumadin or even low dose aspirin because of the elevated risk of gastrointestinal bleeding.

The use of alcohol and these medications is discouraged.

The NSAIDs may cause the blood pressure to rise and may also cause the feet to swell because of their effects on the kidneys.

Is there such thing as a totally safe medication?

When in doubt, the safest over the counter pain reliever is Tylenol or its generic equivalent acetaminophen . It should be taken with caution in those with active hepatitis or cirrhosis of the liver. Furthermore, acetaminophen is found in many over the counter and prescription combination medications such as cold and flu formulas, Vicodin, Darvocet, and certain headache relief medications. When you are using these other medications, be certain not to exceed the safe limit of no more than 4000 milligrams per day of acetaminophen .

How long can I continue to use these medications?

If you use these medications intermittently, you may likely use them safely for your entire life. However, regular daily use requires monitoring of kidney and liver function every six months with a blood test. You should first consult with your primary doctor regarding interactions with other medications you are taking, or whether these medications might aggravate a pre-existing illness.