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The OTC Painkiller Trap—How to Choose Between Acetaminophen and NSAIDs

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Many people assume that over-the-counter (OTC) drugs are less likely to cause dangerous side effects than their prescription counterparts. But that’s not always true—especially when it comes to pain-relieving medications.

Nonsteroidal anti-inflammatory drugs (NSAIDs), a class of painkillers that includes ibuprofen (such as Advil and Motrin), naproxen (such as Aleve) and aspirin, causes more than 100,000 hospitalizations and 7,000 to 16,500 deaths each year.

Acetaminophen, the active ingredient in products such as Tylenol, Panadol and others, is generally safer than NSAIDs. But even this drug, the most popular painkiller worldwide, can cause liver damage and liver failure at too-high doses.

The problem: It’s common for people who have chronic pain—whether it’s from a bad back, persistent headaches or a bum knee—to take multiple doses daily and continue using the drug month after month, greatly increasing the dangers. This is particularly true for older adults, who metabolize drugs differently than younger people and are more likely to have health conditions (such as impaired kidney function) that increase the risks even more.

A SAFER CHOICE

You’ve likely heard that acetaminophen isn’t helpful for painful conditions that involve inflammation, such as arthritis and joint injuries. Studies generally find that NSAIDs are a bit more effective than acetaminophen for arthritis pain, which is one of the main reasons that older adults use OTC painkillers. Still, since acetaminophen is so much safer (when used at recommended doses) than NSAIDs, I almost always advise older adults to try acetaminophen first.

Important: Acetaminophen stops being safe when people exceed the recommended dose. This can happen when people think that they need a higher dose…or when they (often unknowingly) use other products that contain it.

Acetaminophen is an ingredient in dozens of OTC medications, including sleep aids (such as Tylenol PM) and cold and flu remedies (NyQuil and Theraflu). It’s also used in some prescription painkillers (such as Vicodin). If you don’t check ingredient labels, you could wind up taking far more than the recommended limit of 3,000 mg per day. (Aiming to take less than 2,000 mg per day is even safer.)

To prevent liver damage, people with a history of alcohol abuse—or those who drink alcohol frequently—definitely shouldn’t take more than 2,000 mg daily. I advise patients who take daily doses of acetaminophen for long-term problems (such as arthritis) to ask their doctors if their liver enzymes should be checked—either occasionally or regularly.

USE CAUTION WITH NSAIDs

NSAIDs, such as ibuprofen and naproxen, are never my first choice because they frequently cause stomach/intestinal bleeding…increase blood pressure…and lead to kidney damage in those who already have impaired kidney function.

Sobering caution: In 2015, the FDA strengthened existing label warnings on nonaspirin NSAIDs to alert consumers about the increased risk for heart attack and stroke, which can occur even in the first weeks of using one of these drugs—especially when taken at higher doses…and in people with and without heart disease.

Caveat: Because some people get more relief from an NSAID than from acetaminophen, it’s sometimes reasonable to accept the risks of using an NSAID for a short time, such as a few days to a week. But even then, I am cautious about recommending them for patients who take blood thinners (NSAIDs have a blood-thinning effect) or have impaired kidney function or other health problems.

My advice: It’s probably OK for older adults to take an occasional NSAID if they feel acetaminophen doesn’t provide enough relief…but these drugs are not safe for daily use. People with arthritis or other long-term conditions should talk to their doctors about nondrug ways to manage pain, such as weight loss, physical therapy, exercise and cognitive behavioral therapy—all of which have been proven to be effective.

WHAT ABOUT ASPIRIN?

Doctors today almost never recommend aspirin as a pain reliever. Even at low doses (81 mg), it increases the risk for GI bleeding and for cerebral hemorrhage…and the risks for complications are higher among older adults and those with high blood pressure or other chronic diseases.

Aspirin is most likely to cause bleeding and other side effects when it’s taken at doses of more than 100 mg daily for months or longer. But even low doses, as mentioned above, can be risky. Because of these risks, I try to discourage patients from taking aspirin as a pain reliever.

Exception: If you’ve had a heart attack or stroke, your doctor might advise you to take a daily aspirin (typically 81 mg) to prevent blood clots and a subsequent heart attack/stroke. The benefits of this so-called secondary prevention are believed to outweigh the risks.

However, experts no longer recommend aspirin for primary prevention (preventing a first heart attack/stroke) except for certain high-risk patients—for example, someone who has received a stent or has diabetes and another risk factor such as smoking or high blood pressure. Unless a person is at relatively high risk for a cardiovascular event, the risk of bleeding from a daily baby aspirin is generally higher than the chance of avoiding a heart attack or stroke due to this therapy.

THE TOPICAL OPTION

If you feel that you need an NSAID for pain relief, using a topical cream or gel reduces some of the risks. Topical NSAIDs used for musculoskeletal pain are effective, according to a Cochrane (a nonprofit group that evaluates medical treatments) review.

My advice: If your stomach can’t handle oral NSAIDs—and acetaminophen doesn’t seem to work—a topical drug (including OTC topical aspirin, such as Bengay, Aspercreme and other products with salicylate listed on the label) might be worth a try. Some people may also get relief from capsaicin cream.

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Source: Leslie Kernisan, MD, MPH, clinical instructor, division of geriatrics, University of California, San Francisco. Board-certified in both geriatrics and internal medicine, she is founder of BetterHealthWhileAging.net, a website that provides practical information for older adults and family caregivers. She has a geriatric consultation practice in the Bay Area and writes about geriatrics and new technologies at GeriTech.org. Date: February 1, 2019 Publication: Bottom Line Health
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