Houman Danesh, MD
Assistant Professor, Anesthesiology, Rehabilitation Medicine
Icahn School of Medicine at Mount Sinai
Director, Division of Integrative Pain Management
The Mount Sinai Hospital
What You Don't Know About Pain Medications Can Hurt You
As a pain management specialist, I field various questions about pain medications. What does the new NSAID warning mean? Is it OK to drink alcohol while I'm on Tylenol? Is OxyContin safe to take long-term? Well, I'm glad you asked.
NSAIDs
I have known patients to pop ibuprofen (Advil, Motrin) or naproxen (Aleve) like candy. These nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve many types of pain, from headaches and pinched nerves to muscle, back, and knee pain. Sold both over the counter (OTC) and by prescription, they are widely used and readily available -- but they are not harmless.
Most people know about the potential for NSAIDs to cause gastrointestinal bleeding or stomach problems. But the U.S. Food and Drug Administration (FDA) recently strengthened another warning about non-aspirin NSAIDs. They advise that this type of drug "does," rather than "may," increase the chance of a heart attack or stroke.
Here are a few things to keep in mind in light of this new warning:
• Everyone who takes NSAIDs is at increased risk.
• Risk is greater for those with a history of stroke or heart attack or with heart disease or risk factors for it. These people should avoid NSAIDs or at least use them no more than a week at a time.
• If you take NSAIDs, you can lessen your risk by using the lowest dose possible for the shortest amount of time. For example, if you usually take 600 mg at a time, instead try 200 mg, and if that doesn't work, increase to 400 mg.
• If you still have pain after taking NSAIDs for two or three weeks, see a doctor to determine the underlying cause. This will allow you to consider alternative treatments that will decrease your dependence on these medications.
• With certain injuries, such as a sprained ankle, the traditional advice has been to take anti-inflammatory medication. However, inflammation is part of the body's natural way of healing and rebuilding damaged tissue, so see if you can tolerate the pain instead of immediately taking a pill.
• For localized pain (such as in the knee), consider prescription NSAID patches, which provide direct relief and minimize the amount of medication that gets into the bloodstream. Another option is non-NSAID lidocaine patches, which stop pain signals by numbing the nerves.
• Taking NSAIDs before working out increases your risk of kidney failure, so avoid doing so. It is better to stay hydrated to avoid injury and soreness, and then take an NSAID later if you end up needing it.
Aspirin
Although aspirin is also considered an NSAID, it is not included in the FDA's warning because it actually helps prevent heart attacks and strokes. The main thing to be aware of is that it interferes with normal blood clotting for up to seven days, so don't be surprised if you bruise more easily or bleed more if you cut yourself shaving, even if you took just one dose of aspirin several days earlier.
Acetaminophen
Acetaminophen (Tylenol) is generally considered a safe medication when used as directed, but can cause liver damage in high doses or when combined with heavy alcohol use. Be aware of the following:
• Several products, such as Percocet and Vicodin, also contain acetaminophen. "Double dosing" -- taking Tylenol on top of these other medications -- may cause your system to reach toxic levels. The recommended maximum daily dose of acetaminophen for healthy adults is 3,000 to 4,000 milligrams.
• Both acetaminophen and alcohol are processed in the liver. Taking this pain reliever in combination with drinking large quantities of alcohol makes the organ work harder and can result in liver damage.
• While taking acetaminophen, no more than one or two drinks per hour should be consumed, depending on your height and weight.
• You can take acetaminophen for a hangover, but a better treatment is fluids -- not just water, as your body cannot absorb it all, but also drinks like Gatorade or Pedialyte, which replenish the electrolytes lost when consuming alcohol.
Opioid Painkillers
The use of prescription opioid painkillers like Percocet or OxyContin to treat chronic pain (lasting longer than three months) has skyrocketed in recent years. Patients worry about getting addicted, and our country is experiencing a prescription drug overdose epidemic. But focusing the national discussion on addiction diverts attention from the larger issue: There is a complete lack of evidence for opioids' efficacy against chronic pain. No research study has investigated their use for longer than a few months, nor demonstrated that opioids control chronic pain better than NSAIDs or acetaminophen.
Efficacy aside, long-term use of opioids is unsafe. It carries the risk of addiction, raises the risk of falls in the elderly population, and lowers testosterone in both men and women. Decreased testosterone in men leads to increased risk of heart failure, heart attacks, and prostate cancer. Lowered testosterone in women may lead to endometrial cancer. If that weren't enough, more and more studies are finding that long-term use of opioid painkillers can actually increase your sensitivity to pain.
Other important things to know:
• Opioid painkillers are effective and carry less risk of addiction when used short-term, such as to manage severe pain following surgery or from advanced cancer, and to alleviate suffering at the end of life.
• When pain is so severe that patients cannot get out of bed or to a doctor, opioids can serve as a short-term bridge, helping individuals get to surgery or undergo physical therapy, for example.
• Certain medications in the antidepressant and gabapentin families work better than opioids for treating nerve pain, such as from a pinched nerve in your back or shingles, and the medical literature supports their use for longer than three months.
NSAIDs, acetaminophen, and opioid pain medications can all be safe and effective when used properly. If you have any questions about the type that is best for you or the proper way to use it, be sure to consult your physician.