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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Saying What Your Doctor Is Saying

Taking the Pain Out of Pain Relievers

September 12, 2012

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center

Pain relievers must be among the most misunderstood types of medications out there. I get these questions all the time:

Can I take Advil if I'm also taking Aleve?

Can I drink if I'm taking aspirin? What about Tylenol?

I'm worried about my liver. Which pain reliever is safest? Will it harm my kidneys?

Pain relievers are confusing because:

  • There are so many different kinds.
  • Many of the same medicines are available with and without a prescription.
  • Some pain relievers are multi-purpose. It's hard to keep all of their uses straight. Take, for example, aspirin and acetaminophen. Not only are they useful as pain relievers and fever reducers, but aspirin is also used to prevent heart attacks and strokes.
  • Some pain relievers come with "baggage." They may be habit forming and even sold on the street. Many doctors have encountered individuals who will do or say anything to get certain pain relievers because they're addicted or because they plan to sell them.

For all of these reasons, it's important to understand what your doctor is saying about pain relievers. So what do you need to know so that pain relievers are less of a pain? Read on for a quick rundown.

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Categories of Pain Relievers

To get the big picture, think about pain relievers in these broad categories:

  • Mild analgesics (pain relievers) – These are usually recommended for headaches or minor, everyday aches and pains.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) – Arthritis, dental pain and back pain are often treated with NSAIDs, especially if mild analgesics (such as acetaminophen) don't work.
  • Medications for neuropathy (nerve disease) – People with sciatica or diabetes may have nerve-related pain that responds to these medicines; increasingly, these are used for painful conditions other than nerve pain.
  • Muscle relaxants – Back or neck pain due to muscle tension or spasm may respond particularly well to these.
  • Narcotic analgesics – For severe pain, such as after surgery, narcotics may be recommended.

In general, the milder, safer medications at the top of this list are used before stronger medications at the bottom of the list. That's because the more powerful medications may not be necessary and tend to have more side effects.

While some medicines work best when taken regularly (rather than "as needed") for certain conditions, it's generally a good idea to take the minimum amount of pain medication for the shortest time possible.

If a pain medication provides minimal relief or doesn't work at all, it's probably a good idea to stop taking it. Just check with your doctor before stopping any medication he or she has recommended to you.

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Advantages and Disadvantages of Each Type

Each type of pain reliever has its advantages and disadvantages.

Mild analgesics

The most famous member of this group is acetaminophen. As analgesics go, acetaminophen is among the safest. While it rarely works for severe, debilitating pain, acetaminophen can "take the edge off" of mild to moderate pain. For example, headaches, muscle soreness, or other minor aches and pains may respond well to intermittent or regular use of acetaminophen.

It's also a good medication to bring down fever. In fact, common advertisements for acetaminophen take advantage of this point: Ads boast that acetaminophen is "the most widely prescribed pain reliever in hospitals." While that may be true, much of the acetaminophen administered in the hospital is for fever, not pain.

Serious side effects are rare. High doses of acetaminophen can damage the liver. Long-term, high-dose use can cause kidney damage. Minor side effects include rash, itching or other allergic symptoms. Acetaminophen is not strongly associated with stomach pain, ulcers or bleeding.

Non-steroidal anti-inflammatory drugs (NSAIDs)

This category includes ibuprofen (Motrin, Advil, others), naproxen (Naprosyn, Aleve, others), and celecoxib (Celebrex). They counteract chemicals, called prostaglandins and cyclooxygenase, that are involved in the body's regulation of inflammation. As a result, they relieve inflammation and the pain it causes. In addition, NSAIDs are mild pain relievers, so they can work even when little or no inflammation is present.

Side effects include stomach upset, ulcer disease (including serious complications such as perforation or bleeding), kidney injury, ringing in the ears and allergic reactions. Most NSAIDs, including aspirin, thin the blood a bit. Bleeding and bruising may be problematic.

Medications for nerve disease and depression

Drugs in this category include gabapentin (Neurontin) and carbamazepine (Tegretol and others). They work particularly well for pain that comes from neuropathy, but are also effective for many types of chronic pain. A newer medication, pregabalin (Lyrica), is closely related to gabapentin.

Although originally approved for the treatment of depression, amitriptyline (Elavil) and duloxetine (Cymbalta) are commonly prescribed for chronic pain as well.

Side effects vary. Gabapentin and carbamazepine may cause drowsiness or dizziness. Amitriptyline can cause sedation and dry mouth.

Muscle relaxants

Muscle relaxants, including cyclobenzaprine (Flexeril) or methocarbamol (Robaxin) may be helpful for muscle spasm or strain, but they can also relieve pain due to other causes.

Sedation is the primary side effect, so these medicines are usually taken before bed.

Narcotic analgesics

Codeine, morphine and oxycodone are common examples of narcotics. Although tramadol (Ultram) is not technically a narcotic, its actions are quite similar.

Often, these medications are combined with acetaminophen: Tylenol #3 (acetaminophen with codeine), Percocet (acetaminophen plus the narcotic, oxycodone) and Ultracet (acetaminophen plus tramadol). While these are powerful pain relievers, they have several side effects that limit their use. These include:

  • Constipation
  • Nausea
  • Sedation
  • Confusion
  • Tolerance (regular use may render them less effective, requiring higher doses over time)

In addition, they may be habit forming and cause withdrawal symptoms when stopped. They can also interact with other medications.

For these reasons, narcotic pain relievers are used as a last resort, when nothing else has worked. Even so, many people with painful conditions that have not responded to other treatments are able to take low doses of narcotic medications without having to increase the dose or suffering problematic side effects.

Narcotics are more highly regulated than other prescription drugs. For example, in the United States, a physician must provide his Drug Enforcement Agency (DEA) number on the prescription. Your doctor can't "call in" a narcotic prescription to the pharmacy by phone, and the prescription can't be filled for more than one month at a time. So, if you are taking narcotics regularly (for legitimate reasons of course!), don't wait until nights or weekends to call for a refill. Work out a plan with your doctor to refill your prescription each month. Make sure that plan is well-documented in your medical record in case another physician is covering when you call.

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What About Those Questions?

While there's no absolute prohibition against drinking and taking pain relievers, it's important to keep moderation in mind. High-dose acetaminophen and excessive alcohol (more than one or two drinks per day) can damage the liver. Alcohol and NSAIDs can irritate the lining of the stomach. The sedative effects of alcohol can be dangerously exaggerated by the addition of a narcotic. Avoid mixing the two.

In general, you should not take two different types of NSAIDs at the same time for pain relief. If in doubt, ask your doctor or pharmacist. The one exception, however, is if you take low-dose aspirin to prevent heart attack or stroke. It's common for a person to take another NSAID such as ibuprofen with low-dose aspirin. In this case, take the aspirin at least 30 minutes before the ibuprofen, so that it still can provide its blood-thinning effect. Check with your doctor before combining delayed-release aspirin and ibuprofen. It's possible that regardless of timing, the aspirin benefit may be reduced.

It is common and acceptable to combine acetaminophen and NSAIDs when necessary.

Serious liver disease is uncommon with the pain relievers listed above. Kidney disease, however, is a significant problem with NSAIDs and possibly with long-term high-dose acetaminophen. So, if you have chronic kidney disease, it's best to check with your doctor before taking any pain reliever.

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The Bottom Line

Treating pain depends at least in part on the cause. So, your doctor will want to know the details of your pain and examine you carefully to figure this out. Keep in mind that pain can often be treated without medications. Heat, ultrasound treatment (with a physical therapist) and rest are good examples of non-pharmacologic options for pain.

But if your doctor does recommend a medicine for pain, now you'll have a better understanding of what your doctor is saying.

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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program

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