DOCTOR'S VIEW ARCHIVEMedicineNet.com: Welcome to Doctors Dialogue, featuring the doctors of MedicineNet.com. This segment features Dr. Dennis Lee, Board certified in Internal Medicine and Gastroenterology, and Dr. William Shiel, Board certified in Internal Medicine and Rheumatology. Dr. Lee will be asking Dr. Shiel pertinent viewer submitted pain management-related questions.
Dr. Lee: Many pain medications are available over-the-counter
(without a prescription, or OTC) in the U.S. for short-term relief of
joint pain, muscle aches, headache, menstrual cramps, and fever. These OTC
analgesics are generally well tolerated and safe when used properly. But side
effects do occur and in some instances can be serious. Today, we will ask Dr.
William Shiel how to use these analgesics properly in order to minimize risks
and side effects. We will also ask him to compare traditional pain relievers with the newer pain relievers, the selective COX-2
What pain medications are available in this country without a doctor's prescription?
Dr. Shiel: There are two major classes of
pain relievers available in this country without prescription; they are
acetaminophen (Tylenol) and
Non-steroidal anti-inflammatory drugs
Quick GuideChronic Pain Syndrome: Treatment and Management for CPS
Dr. Lee: What are Non-steroidal anti-inflammatory drugs?
Dr. Shiel: Non-steroidal anti-inflammatory drugs are medications that impair the production of prostaglandins in the body. Prostaglandins are natural compounds that are responsible for producing fever, pain, and inflammation.
Dr. Lee: Why are they called non-steroidal anti-inflammatory drugs?
Dr. Shiel: They are called non-steroidal anti-inflammatory drugs because they reduce inflammation without the side effects of steroids. Steroids (Prednisone, Cortisone, Medrol, etc.) are potent medications that reduce inflammation, but steroids have predictable and potentially serious side effects, especially with long-term use. Non-steroidal anti-inflammatory drugs do not have these steroid side effects.
Dr. Lee: Can you give me some examples of non-steroidal anti-inflammatory drugs that are available OTC?
Dr. Lee: Are steroids such as Medrol, Prednisone, and Cortisone pain relievers?
Dr. Shiel: No, steroids are not pain relievers. But this is a common misconception Dr. Lee. Steroids, including Cortisone, are potent medications that reduce inflammation. And reducing inflammation can cause the pain to gradually subside. But steroids are not used specifically for quick pain relief.
Dr. Lee: How are over-the-counter NSAIDs different from NSAIDs that need prescriptions from the doctor?
In fact, many over-the-counter
NSAIDs have the same active ingredients as prescription NSAIDs. The difference
is in the amount of active ingredient contained in each tablet or capsule,
and in the dosing requirements (how often one has to take these per day).
For example, Aleve is available over-the-counter and contains 220mg of naprosen sodium per pill, while Naprosyn needs a doctor's prescription and may contain 375mg or 500 mg per pill.
Dr. Lee: Let me get back to the over-the-counter pain relievers. How is acetaminophen different from NSAIDs?
Dr. Shiel: Acetaminophen reduces pain and fever by acting on the brain. NSAIDs reduce pain and fever by reducing prostaglandin production and inflammation at the site of pain (ankle, knee, shoulder, etc.) Acetaminophen is generally considered easier on the stomach than NSAIDs.
Dr. Lee: How is aspirin different from the other NSAIDs like Aleve, Motrin or Advil?
Aspirin, Aleve, Advil/Motrin are
similar in reducing pain, fever and inflammation. But aspirin has
more prolonged anti-platelet effect than the other NSAIDs.
Platelets are small particles in the blood that initiate blood clot formation. For example, a heart attack is usually caused by a blood clot blocking the flow of blood in an artery to the heart. Aspirin inhibits the platelets from forming blood clots, and therefore is being used in low dose to prevent heart attacks and strokes.
The other NSAIDs also have anti-platelet effects. But their anti-platelet action does not last nearly as long as aspirin
Dr. Lee: Bill, how does one go about choosing an OTC pain reliever?
Dr. Shiel: Different people respond differently to pain relievers. Therefore, choosing the right pain reliever can be somewhat of a trial and error process. I recommend that patients use the pain reliever that has worked for them in the past. This will increase the likelihood of effectiveness and decrease the risk of any side effects.
Dr. Shiel: Over-the-counter pain relievers have been shown to be safe and effective for short-term relief of pain when used properly according to the label instructions. By short-term I mean no more than ten days. Anybody with persisting or severe pain ought to consult a doctor for proper evaluation and accurate diagnosis.
Dr. Lee: Any special precautions while using acetaminophen?
acetaminophen is safe and well tolerated, it can cause severe liver damage and liver failure in high (toxic) doses.
You and I have both taken care of patients with liver
failure as a result of acetaminophen overdose in suicide
attempts. Acetaminophen can also damage the kidneys when taken in high
amounts. Therefore, it is crucial that acetaminophen not be taken more
frequently or in higher quantities than recommended on the label of the bottle or container.
I also do not recommend acetaminophen to patients with existing liver disease, and in those who regularly consume moderate to heavy quantities of alcohol.
brought up a very important issue. Even though most of us
know that acetaminophen can cause serious liver damage in toxic doses, not many
people realize that even non-toxic doses of acetaminophen can cause liver
damage in people who regularly drink alcohol in moderate to heavy
Ten years ago, I took care of a 30 year old gentlemen who mysteriously developed acute liver failure and coma after taking multiple doses of acetaminophen for "flu" symptoms over the weekend. Fortunately, the doctors at a nearby liver transplant center were able to perform emergency liver transplantation. He is doing very well now. While the exact cause of his liver failure remains a mystery, I strongly suspect it was caused by the combination of moderate alcohol use along with excessive though non-toxic amounts of acetaminophen intake.
Let me make another important point. Many over-the-counter cold and flu remedies contain either aspirin or acetaminophen along with other active ingredients. Always study the active ingredients or consult the pharmacist before using them, especially if you drink alcohol regularly or have existing heart, liver, or kidney diseases.
Any special precautions while using aspirin?
Yes, aspirin should especially be avoided by children and teenagers
with chickenpox and "flu" because of risk of Reye Syndrome,
a potentially serious medical condition.
Aspirin should be avoided by patients who are taking blood-thinning medications such as Coumadin because it can increase the risk of bleeding. I also do not recommend aspirin for patients with active ulcers of the stomach or bowels because it can impair ulcer healing, aggravate ulcers, and also increase the risk of ulcer bleeding.
I also do not recommend aspirin to patients who have a history of balance disorders or hearing difficulties because aspirin potentially can aggravate these conditions.
Dr. Lee: Any special precautions while using non-aspirin OTC NSAIDs?
Patients taking blood thinners, such as Coumadin, should not take OTC NSAIDs
without doctor supervision. NSAIDs can increase the risk of bleeding.
Patients with active ulcers should not take OTC NSAIDs because NSAIDs can impair ulcer healing, aggravate ulcers, and also increase the risk of ulcer bleeding.
taking care of patients with liver disease, I also do not recommend NSAIDs to
my patients with advanced liver disease. Patients with advanced liver disease
also have impaired kidney function. I'm concerned about the effect of NSAIDs on the
kidneys in these patients. Any worsening of kidney function in these patients can cause rapid
and life-threatening deterioration of their liver disease.
Are there any other conditions you can think of that should lead to cautious use of NSAIDs?
Dr. Shiel: Yes Dennis, you bring up an excellent point. I recommend that patients with underlying heart disease, kidney disease and the elderly consult their doctors prior to using any over-the-counter medication.
Dr. Lee: Let's now go to the areas of prescription use of pain relievers and NSAIDs. Firstly, Bill, what are the NSAIDs that are available by prescription only?
Dr. Shiel: There are more than twenty prescription NSAIDs currently available in the United States, and the number is growing as new NSAIDs are added to the market yearly. Examples of traditional prescription NSAIDs include Feldene, Naprosyn, Indocin, Tolectin, Clinoril, Relafin, and Voltaren. Then, there are the newer selective NSAIDs called COX-2 inhibitors such celecoxib (Celebrex.)
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Dr. Lee: What are the selective COX-2 inhibitors?
Dr. Shiel: COX-2 inhibitors are different from the traditional NSAIDs. Traditional NSAIDs reduce pain and inflammation but they also reduce prostaglandins in the stomach. A decrease in stomach prostaglandins increases the risk of stomach ulceration. COX-2 inhibitors such as Vioox and Celebrex reduce pain and inflammation without reducing the prostaglandins in the stomach. Patients who take COX-2 inhibitors have been shown to have less bleeding from ulceration than those who take traditional NSAIDs.
Dr. Lee: I gather you mean that the COX-2 inhibitors generally have less stomach side effects than the traditional NSAIDs. But how about pain and inflammation relief? Are they just as good, better, or worse than traditional NSAIDs?
Dr. Shiel: The selective COX-2 inhibitors have been shown to be equally effective as the traditional NSAIDs. This means that they have been shown to be as potent as traditional NSAIDs in relieving pain and inflammation.
It is important to understand that selection of anti-inflammation
medicines for arthritis has to be individualized. The doctor must consider
the type and severity of the arthritis, patient's age, prior side
effects and responses to different NSAIDs, as well as any co-existing medical conditions
such as heart, kidney, and liver disease.
After making the proper selection, the doctor will try to use the lowest effective dose of the medicine in order to minimize risks and side effects.
For example, if a patient has a history of ulcer bleeding and needs long term NSAIDs, I would prefer to use the selective COX-2 inhibitor Celebrex. Alternatively, I will consider combining a traditional NSAID with Prilosec or Cytotec, medications that can protect the stomach from ulcerations.
Dr. Lee: In your experience Bill, how effective are NSAIDs in reducing pain, inflammation and helping your patients function?
Dr. Shiel: In my patients with arthritis and chronic inflammation, NSAIDs can be critical to maintain daily functions and sense of well being. Many of my patients report significant flare of pain and arthritis if they miss just one dose. NSAIDs are essential part of treatment of the inflammation of chronic arthritis.
Dr. Lee: What happens when NSAIDs don't do the trick, and the pain and the inflammation persists?
Dr. Shiel: In the setting of intense pain or persistent pain, in patients who are already taking NSAIDs, we can supplement with short-term narcotic pain relievers. The reason we prefer to use narcotics short-term is because narcotics have the potential for habituation, which means the patient may require higher and higher doses for pain relief, and that they become habit forming.
Dr. Lee: What are some of the examples of narcotic pain relievers that you use?
Dr. Shiel: Typical narcotic pain relievers that we use include Codine or Codine derivatives and Darvocet or related medications to Propoxaphine and Ultram.
Dr. Lee: Thank you, Bill, for sharing with us your perspective on proper use of pain relievers in your practice and also for reviewing the use of over-the-counter pain relievers.
Dr. Shiel: Thank you Dennis for your questions.
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