Painkillers: A Guide to What Works
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Painkillers: A Guide to What Works

When something hurts, you want a pill that will make it go away now. Our guide helps you figure out which OTC and prescription drugs really work.

Pain Meds 101

A trip to the drugstore changed my life. When I was a teenager, in the '80s, my periods were rough. I tried those popular pills for pain and bloating, heating pads, pleading with the universe -- but nothing worked. Then ibuprofen became available without a prescription. My next period was a totally different experience. At the first twinge of pain, I popped two pills and was back to normal in 30 minutes.

I'm not the only one who's grateful for painkillers. Women are hit harder by pain than men are -- not just from cramps but also from conditions such as migraines, fibromyalgia, and rheumatoid arthritis. The reason is twofold, says Michel Y. Dubois, MD, professor of pain medicine and palliative care at NYU Medical Center. "There are differences in the pain-processing circuitry between men and women," he says. And estrogen may increase the perception of pain. Some 22 percent of women report severe headache or migraine pain, 30 percent have back pain, and 33 percent have joint pain, according to the National Center for Health Statistics. Up to 90 percent of people with the chronic pain disorder fibromyalgia are women, and migraines are two to three times more common in women than they are in men.

Fortunately, there are a lot more options for managing pain than there used to be. The "grin and bear it" attitude is out and the "get ahead of the pain" approach is in. The main message? Most people can find a medicine that helps them feel better with minimum side effects and risk.

For basic aches and pains

Generic name: Acetaminophen (also known as paracetamol or APAP)

Common brand name: OTC: Tylenol; Prescription: Tylenol 3 (with codeine, for mild to moderate pain).

The basics: No one is really sure how it works, says Ewan McNicol, clinical pharmacist at Tufts Medical Center and assistant professor of anesthesiology at Tufts University, but it seems to control the way pain is perceived in the brain rather than attacking its source. The over-the-counter pain reliever can alleviate headaches, sore throat, and muscle and joint pain -- and reduce fever -- but so can NSAIDs and aspirin (see following categories). "In general, acetaminophen is a safer drug," says McNicol, so many experts suggest trying it first. But NSAIDs or aspirin may work better for some conditions, especially if inflammation is involved.

The issues: While acetaminophen is safe, misusing it can cause liver damage. Don't take more than 1,000 mg at a time or 4,000 mg a day (3,000 mg if you're over 65 or regularly drink alcohol). The major reason people go overboard on the drug is that they unknowingly take more than one medication that contains it. (According to the FDA, more than 600 OTC and prescription products are made with acetaminophen.) For instance, when you have a cold, you might pop acetaminophen to nix the body aches and take a nighttime multisymptom remedy so you can sleep. If that cold remedy also contains acetaminophen, you just took a double dose, so read ingredient lists carefully.

When using acetaminophen in any form, watch your alcohol intake because the combination can harm your liver.

NSAIDs and Aspirin

For headaches, body aches, osteoarthritis, menstrual cramps, mild burns, dental pain, and soft-tissue injuries

Generic names: Nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen and naproxen (OTC) and celecoxib, diclofenac, and etodolac (prescription).

Common brand names: OTC: Advil, Aleve, Motrin. Prescription: Anaprox, Celebrex, Lodine, Voltaren.

The basics: NSAIDs inhibit production of enzymes (COX-1 and COX-2) that help form prostaglandins, the chemical messengers that play a role in pain, inflammation, fever, and achy muscles.

The issues: COX-1 protects the stomach lining, so when you block it by taking ibuprofen or naproxen you can irritate your stomach and raise your odds of ulcers. You might have a problem if you take the maximum dose for weeks or months, says Andrew Chan, MD, a gastroenterologist at Massachusetts General Hospital. But the majority of people who occasionally use NSAIDs don't have to worry. Prescription COX-2 inhibitors were developed to minimize stomach damage, but then studies found that people who used them to treat conditions like arthritis were more likely to develop blood clots, which can lead to a heart attack or stroke. Even over-the-counter NSAIDs carry some heart risk, and naproxen appears to be the safest choice. For women at low risk, it's highly unlikely that taking an NSAID for cramps or a toothache will cause a heart attack, says Gina Price Lundberg, MD, director of the Heart Center for Women at Saint Joseph's Hospital in Atlanta. If you have heart disease or plan to be on NSAIDs for the long term, discuss the risks with your doctor.

For headaches, menstrual pain, arthritis, toothaches, muscle aches

Generic name: Aspirin

Common brand names: OTC: Bayer, Bufferin, St. Joseph, and dozens of other products contain aspirin alone; some brands, such as Excedrin, may contain caffeine, acetaminophen, or other ingredients in addition to aspirin.

The basics: Aspirin, part of a group of drugs called salicylates, reduces substances in the body that cause pain, fever, and inflammation. Aspirin also has anticoagulant properties, meaning it prevents blood from clotting easily. More than 50 million people in the United States take low-dose aspirin to prevent heart disease.

The issues: Like NSAIDs, aspirin can cause ulcers and bleeding in your stomach if you take it over the long run. "The problem with aspirin is it's very short acting, so you have to take it often, which means more exposure to the lining of the stomach and a greater risk of bleeding," says Scott M. Fishman, MD, chief of pain medicine at University of California, Davis. And because it's an anticoagulant, it increases the risk of bleeding even further. Talk to your doctor about your risks if you take it regularly. Also, don't give aspirin to children or teenagers who have a fever, especially if they have flu-like symptoms or chicken pox, because it can cause a sometimes-fatal condition called Reye's syndrome.

For Migraines

Generic names: Triptans, including sumatriptan (sometimes with naproxen) and rizatriptan.

Common brand names: Imitrex, Maxalt, Treximet

The basics: The pain and other symptoms of a migraine arise from a cascade of events involving the brain chemical serotonin, the trigeminal nerve (responsible for facial sensations), and blood vessels in the brain. These changes trigger the release of pain-producing substances and cause blood vessels to dilate. Triggers may include hormonal changes, stress, certain foods, and more. "Medications called triptans reduce inflammation and constrict the vessels so they go back to their normal size," says Brian Grosberg, MD, co-director of the Montefiore Headache Center in the Bronx, New York. Triptans can also ease the nausea and light sensitivity that accompany a migraine.

The issues: These drugs are most effective if you use them as soon as you feel a migraine coming on. "After the pain has built up, it's harder to treat," says Dr. Grosberg. Potential side effects include nausea, dizziness, muscle weakness, or a sense of warmth or tingling. Don't use these drugs if you have heart disease.

For acute pain after surgery or from an injury, or for serious chronic pain

Generic names: Prescription opioid narcotics have many generic names, including codeine, fentanyl patch, hydrocodone, methadone, morphine, and oxycodone.

Common brand names: Avinza, Kadian, MS Contin, OxyContin, Percocet, Tylox, Vicodin

The basics: Opioids mimic the body's natural pain-relieving endorphins; they bind to nerve receptors so pain messages don't travel to the brain. Opioids also boost levels of the feel-good neurotransmitter dopamine, which improves your ability to tolerate pain.

The issues: Some opioids, like Vicodin and Percocet, also contain acetaminophen and carry the same risk to the liver. Because of that, the FDA decided to phase out prescription medications that have more than 325 mg of acetaminophen per pill (they'll be gone within two years). Opioids can make you nauseous and groggy for the first few days, but you should improve as your body adjusts to them. Because these drugs slow the digestive tract, constipation is often a problem. Opioids also pose a small risk of addiction.

Never combine opioids with alcohol, antihistamines, sleeping pills or anti-anxiety drugs without checking with your doctor first, says Dr. Fishman. Doing so could lead to depressed breathing, which is how the actor Heath Ledger died after he combined two sedatives, two pain-killers, and two anti-anxiety drugs.

For nerve pain, like diabetic neuropathy, and muscle and joint pain

Generic names: Antidepressants and other drugs in that class, such as amitriptyline, desipramine, duloxetine, milnacipran and nortriptyline.

Common brand names: Cymbalta, Elavil, Endep, Norpramin, Savella

The basics: It's a vicious cycle -- being in pain can lead to depression, and being depressed makes you hurt even more. These medicines improve mood and directly target the discomfort. "Antidepressants stabilize the membranes surrounding nerve cells, making the cells less likely to fire when they shouldn't," says Dr. Fishman. That means fewer pain signals are sent to your brain.

The issues: Antidepressants may cause sleepiness, nausea, sexual dysfunction, and jitteriness; sometimes they also blunt your emotions. It's often a matter of trial and error to find one that you can tolerate -- but don't stop taking them without talking to your doctor.

Alternative Pain Remedies

Pain experts agree that you should use a range of treatments to get the most relief. Try adding one or two of these complementary therapies to your routine.

Acupuncture: Many solid studies support its effectiveness. Some people need weekly treatments.
Topical creams and gels: Capsaicin creams can help soothe pain from arthritis, shingles, or muscle strains. You can also try arnica gel. Made with the herb arnica montana, it's best for injuries that cause bruising and swelling but also helps with joint and muscle pain.
Biofeedback: Using machines, computer programs, and electrical technology, you monitor your body's reactions and learn to control pain levels.
Cognitive behavioral therapy: This treatment can help you deal with issues that may exacerbate your pain, like stress, anxiety, sleep problems, and negative thinking.
Guided imagery: You imagine soothing sensations like dipping your hand in anesthesia, feeling it go numb, and then rubbing it over a painful area.
Therapeutic touch and reiki: These techniques use subtle energy to activate your self-healing abilities. The research is mixed.
Ice: It can help reduce inflammation and calm overactive nerves.

Originally published in Ladies' Home Journal, May 2012.

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