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New Advice on Pain Relief
Pain relievers can work wonders, allowing
many people to carry on with their lives despite disabling arthritis,
for instance, or recurrent headaches. But all pain relievers,
prescription or over-the counter (OTC), have potential risks, especially
when used long term for chronic pain. Recent studies have raised
concerns—some new, some old—about these widely used
drugs. In December the FDA proposed tougher warnings on labels,
but it may take a year for these to appear on packages. Here
are the concerns—and what to do about them.
Two things to note first. Though there
are many brands of OTC pain relievers, there are only two basic
types: acetaminophen (such as Tylenol)
and NSAIDs (nonsteroidal anti-inflammatory
drugs), all available in generic form. NSAIDs include aspirin,
ibuprofen (such as Motrin and Advil), and naproxen (such as Aleve).
These and other NSAIDs are also sold by prescription, usually in
stronger dosages.
Second, the issues below relate primarily
to people who take these drugs at least several times a week.
• Cardiovascular
risk. Based on accumulating research, a new report from
the American Heart Association (AHA) concluded that NSAIDs,
with the exception of aspirin and probably naproxen, increase
the risk of heart attacks, especially in people who already
have cardiovascular disease or are at high risk for it. The
so-called COX-2 inhibitors (Celebrex, sold by prescription,
is the only one still marketed) pose the highest risk, followed
by ibuprofen. Like aspirin, though to a lesser extent, naproxen
may actually reduce the risk of heart attacks by making blood
less sticky.
• Blood
pressure. All OTC pain relievers, including acetaminophen,
can raise blood pressure, and this may be at least partly responsible
for the increased risk of heart attack and stroke. A new study
of 16,000 male health professionals (age 56 to 76) without
hypertension found that those who took pain relievers most
days were about one-third more likely to develop hypertension
over a four-year period. In 2002 a large study found that daily
use could increase the risk even more in women.
• Gastrointestinal
bleeding. NSAIDs can damage the stomach lining and cause
bleeding and ulcers—this has long been considered their
major drawback, as the labels warn. The risk is greatest in
long-term users, those over 60, those drinking three or more
alcoholic beverages a day, those with a history of GI bleeding
or ulcers, and those taking certain medications, such as blood-thinning
drugs or steroids.
• Liver
damage. Acetaminophen, the No.1 nonprescription pain
reliever, does not cause GI bleeding, but excessive use—either
long-term frequent use or very large single doses—can
cause severe liver damage. In fact, acetaminophen overdosing
is the most common cause of acute liver failure in the U.S.
A new survey from the University of Michigan found that most
people don’t know about this risk. They also don’t
realize that this ingredient is in hundreds of OTC cold, allergy,
and headache products and some prescription pain relievers.
Check labels for acetaminophen, and don’t take more than
four grams a day from all sources (equal to eight Extra-Strength
Tylenol). Drinking alcohol significantly increases the risk.
Heavy drinkers and those with liver disease should avoid, or
at least limit, acetaminophen use.
The take-home messages
The risks posed by OTC pain relievers,
even when taken regularly, may be relatively small, but because
these drugs are so popular, thousands of people are affected. Don’t
let these concerns prevent you from taking drugs if you need them,
but do follow this advice, especially if you take pain relievers
often:
• First
try nondrug treatments for chronic pain. For arthritis,
that means physical therapy, exercise, weight loss to
reduce stress on joints, and heat or cold therapy. It’s
easier to pop a pill, but these treatments may work just as
well or even better, without the potential dangers.
• If
these do not help enough, talk to your doctor about which pain
reliever is best for you to take on a regular basis. Weigh
the potential risks and benefits of each drug. This is especially
important for people with cardiovascular disease (or at high
risk for it) or uncontrolled hypertension, as well as those
who drink moderately or heavily.
• The
best choice depends on the cause and severity of your pain,
along with your medical history. In general, consider
acetaminophen first, and then aspirin or naproxen, according
to the AHA advisory. Acetaminophen is safest for the GI tract,
but may not provide enough relief for some arthritis sufferers,
since unlike NSAIDs it doesn’t reduce inflammation. Ibuprofen
may provide more relief at standard doses than other OTC options,
but it also appears to pose more cardiovascular risk. Your
doctor may recommend a prescription drug instead of long-term
use or high doses of OTC products. Celebrex should be only
a last resort.
• Take
the lowest effective dose for the shortest time possible, whatever
the pain reliever.
• Do
not exceed the doses listed on the labels or take for
more than 10 days, unless your doctor has said it’s okay.
• Talk
to your doctor before starting low-dose aspirin therapy to
protect your heart. Once you’re taking it, don’t
stop unless your doctor has advised you to do so.
UC Berkeley Wellness Letter, June 2007
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