Over-the-counter pain medications 101
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For a decade plus, when I would get my period, I would have terrible cramps the first day, and I would just ride it out. Like I'd be doubled over, unable to leave the house, really. I tried heating pads, which do help, but for some reason, I didn't think I should take a painkiller. I don't know, I guess I just thought it was safer to go natural.

But then one day when I was maybe 25, I popped an ibuprofen and then a short time later, the pain was gone. It would start to creep back up again a little later. And then I took another. And after that, I was over the hump. My cramps were manageable at that point. I kind of regretted waiting that long. I went through so much unnecessary pain.

Pain is a part of the human experience. We get cramps and aches and migraines. We burn our hands cooking or trip and sprain an ankle. And when you're right in the middle of one of these moments and feeling that pain deep down in your bones, painkillers, especially the over-the-counter kind that are easy to get, they feel like a miracle. Now, they are not without risks. If you take over-the-counter painkillers the wrong way or take too many of them, you can have serious complications or even die.

And they can mask your problems, too. Pain is there for a reason. It's one of the ways our bodies warn us that something's wrong. Dr. Trisha Pasricha is an instructor at Harvard Medical School. And she says we need to consider that when we're thinking about taking painkillers.

I think there's a question that we should ask ourselves when we have pain, which is that, is this like sort of a one-time thing or once in a blue type of moment that I'm having? Or am I going to the doctor all the time for pain? And is it the same kind of pain? Because I think in my mind, that really differentiates what we need to be doing about it. Because if this pain keeps coming up, it might be time to see a doctor, make sure everything's okay.

LifeKit reporter Andy Tegel has been looking into how we use over-the-counter drugs. And in this episode, we're going to talk specifically about painkillers like acetaminophen and NSAIDs, non-steroidal anti-inflammatory drugs, ibuprofen, naproxen, aspirin, and the like. These are some of the most commonly used over-the-counter medications. Andy talked to Dr. Pasricha and to two pharmacists, including Blama Twagby at UCSF's outpatient pharmacy at Mission Bay, who says...

Yeah, talk to your pharmacist. This is their world and they have the training to help you. And we can help you make a safe choice. And we'll ask you questions that you may not even think about, like what other medications are you taking? Oftentimes there can be drug interactions with prescription medication and an over-the-counter med. So it's really to your benefit to ask a pharmacist about what you should use. Andy and I are going to talk about how to use these drugs safely, what they're each good at, and what you might consider if you're looking for an alternative.

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Okay, to start, I've always wondered, why are some meds available over-the-counter while others require a prescription? Yeah, me too. It's a good question. So if a medicine is available over-the-counter, that means it's been deemed safe and effective by the FDA for most people, if used correctly, and they have to meet three basic criteria in order for that to happen. One, you have to be able to self-diagnose the problem, like, I have a headache.

From there, two, you have to be able to self-treat that headache. And then three, there has to be a low potential for misuse and abuse. All of these medications are tested and regulated through something called a drug monograph. And what those are are kind of a recipe book, which cover acceptable ingredients, doses, formulations, and labeling. These are continually updated by the FDA to make sure that the public is safe and informed.

But if you use over-the-counter meds the wrong way, you could die, right, in some cases? They're not without risk. They can be fatal or addictive. Yeah, Mariel. Just because an over-the-counter med is deemed safe doesn't mean they can't still be harmful.

So Dr. Trisha Pasricha, she's the physician we heard at the top, and she's also done a lot of research in neurogastroenterology, says we all know we should take our medications as directed by the label and our medical provider, but that's just not always how it happens.

There was a study in 2018, which I cite often, which found that more than a third of over-the-counter ibuprofen users were taking other NSAIDs like aspirin and naproxen at the same time. And most of those people didn't realize all the products they were taking were NSAIDs in the first place.

So what that means is you can easily enter this false sense of security that everything you get over the counter must be completely safe. And that's really not true. They can be safe and they can be effective. But you need to take the time to understand what it is you're treating, be confident that medication you're taking treats that thing, and be clear on the optimal way to take it. For example, Pasricha mentioned patients of hers who suffer from heartburn. So

So they would take proton pump inhibitors like Prilosec and would reach for that medication right before bed. Well, right before you go to bed is not a very helpful time to take it. It would have been much more efficacious if you'd taken it 30 minutes before your meal. Sometimes that entire instruction just gets lost in translation and they think that, well, the proton pump inhibitor isn't working. This medication isn't working for me. I have something else going on or my body

my heartburn is refractory to medication. Actually, that's not the case at all. It's just that we weren't taking the medication optimally. And sometimes having a conversation with your healthcare provider, say, this is what I've been trying, could help clear that right up. Yeah, so who can we talk to about over-the-counter drugs?

and how to use them if we're not sure. Yeah, good news on that front, Marielle. You don't have to make an appointment with your doctor. There are other trained professionals out there ready and willing to help with this exact problem. So just like we heard at the top from UCSF pharmacist Plama Twegby, you can walk into any local pharmacy and talk to your pharmacist. When you do that, they'll need to know what chronic diseases you have, what medications you're taking, and a note that should include any vitamins or supplements. All right, let's get into some of the specifics. What is a chronic disease?

One commonly used over-the-counter painkiller is acetaminophen, also known by the brand name Tylenol. And it's used for fevers and body pain. So, yeah, the experts we talked to would agree that's the go-to reason. And they would also recommend reaching for acetaminophen first because, generally speaking, it's gentler on the body than NSAIDs and the safer choice overall. With some caveats. Yeah.

Yeah, what are the risks if you're taking acetaminophen? This is the one I know can cause liver damage if you take more than you're supposed to. Yeah, that's exactly right. So it's called acetaminophen toxicity. And according to recent data, it's one of the most common causes of liver transplantation in the U.S. And it is responsible for over 56,000 emergency room visits, over 2,600 hospitalizations, and 500 deaths per year.

Now, I know that sounds horrible, but when used appropriately and safely, most people don't have to worry. This is Candy Cerunas. She's a professor of clinical pharmacy, also at UCSF, and some of her work entails educating providers and patients about the appropriate use of medicine. Okay, so what is the recommended dosage for acetaminophen to keep your liver safe?

The maximum dosage is no more than 4 grams or 4,000 milligrams in 24 hours. And you also want to be really careful of alcohol consumption because alcohol is also hard on your liver. So doing both increases your risk of severe liver damage. I asked our experts if they could give us any hard and fast rules around drinking and Tylenol. You know, is there a time limit maybe or within a 24-hour period, a certain number of drinks?

And they said that's not really how it works. But Pasricha says the thing about acetaminophen toxicity is it's often an acute presentation, meaning the damage hits hard and fast. It's often because they're drinking heavily. You feel a little sick after you've had a lot to drink, and then you might start to kind of lose track of how much you're self-medicating at that point.

So clearly that's something you want to avoid. So Saruna says there's no magic number here, but if you have any pre-existing liver condition, liver disease, best to avoid acetaminophen.

And then more generally, if you know you've been drinking and then say you're suddenly hit with a fever or you sprain your ankle, that's probably an instance to look for other pain relief options. The moral of the story is if you're a regular drinker of alcohol, that you might want to avoid using acetaminophen as your primary pain reliever. But again, I always would recommend that people talk to their pharmacist or their doctor about the details.

Any other drug interactions we should know about with acetaminophen? You know, alcohol is a biggie. If you're on blood thinners like warfarin, that's the only other major one often mentioned. Any other prescription meds you have will likely come with a warning label saying you shouldn't take it with acetaminophen. But of course, talk to your doctor, talk to pharmacists if you have concerns.

All right. Another commonly used over-the-counter painkiller is the NSAID, which stands for non-steroidal anti-inflammatory drug. I'm assuming these work by lowering inflammation in the body? Yeah, exactly. So these drugs do what they sound like they do. They reduce pain by limiting your body's production of certain chemicals that cause inflammation. So you want to reach for these if you're dealing with any type of swelling, bruising, muscle aches and pains, you know, a headache, a sprained ankle, muscle soreness after a big workout.

Acetaminophen, on the other hand, works differently. It's a bit of a black box, but we know it works on different pain receptors and helps reduce and regulate body temperature.

That's why your doctor or pharmacist will often steer you in one clear direction for fever, but for pain, it's not so clear-cut. Depending on the kind of pain, and it can sometimes be hard to know when you're just like, well, I have a headache or my back hurts. It's hard to know sometimes exactly what's driving it. Maybe musculoskeletal injury, it may not be. Pain often has an inflammatory component to it, in which case people often find that NSAIDs are just much more efficacious for pain than acetaminophen.

And then it's also confusing when you're walking through the medicine aisle, right? Because with acetaminophen, there's just the one drug, but there are lots of different types of NSAIDs. So how do you know which one to choose? Is there one that's stronger than the others or more effective for certain kinds of pain? Yeah. So let's compare just two of the most popular well-known NSAIDs.

Ibuprofen, brand names like Advil or Motrin, and naproxen, brand name Aleve. Naproxen, or Aleve, is longer lasting. So you only have to take it every 8 to 12 hours, and there's a maximum daily dose of 660 milligrams. So if you're someone who doesn't like taking pills, that might be appealing. But some people find that naproxen makes them drowsy, so you have to make sure that's a side effect that you can plan for.

Ibuprofen, on the other hand, doesn't last as long. You take them every 4-6 hours as needed and you can take up to 1200 mg a day. So if you're looking for more regular, quicker hits of relief throughout the day, maybe you're dealing with newer pain like from a break or a fall, this type of NSAID might make more sense for you. Okay. Also, it seems safe over the counter for the 12 and younger crowd while naproxen isn't. So any parents can take note there.

Bottom line, best is relative. And importantly, each medication comes with risk and potential side effects. Okay, and what are the risks of taking NSAIDs? Yeah, so, you know, a lot of people will choose NSAIDs over acetaminophen because they find them more effective. The thing about that is they can also be riskier. So with a lot of NSAIDs, there are potential effects on the kidneys and the GI tract, which is why it's important not to take these meds on an empty stomach. You want to give yourself some buffer.

Taking NSAIDs could lead to minor uncomfortable side effects like gas, heartburn, nausea, diarrhea, up to more serious complications. Specifically, they could have an impact on the blood flow in the stomach and the small intestines that might lead to gastrointestinal ulcers or bleeding. So Pasarisha says if you feel sudden, sharp stabbing pains in your gut or if your stool is black after taking these meds, those are emergency room situations because they could be signaling some of those more serious gastrointestinal problems.

And her big problem with NSAIDs is that she says sometimes even if you're following the recommended dosage and usage, you can still experience negative side effects if you take them over a longer period of time.

There are many formulations, but you can stick to the exact instructions. But if you do that every single day and you do it chronically, even sort of going by the book, you have put yourself at higher risk of damage. And that's just because of the nature of the medication. Okay. And are there any drug interactions we should know about when it comes to NSAIDs?

Yeah, there are a few more than acetaminophen. So if you're somebody who's taking a regular blood thinner, if you have atrial fibrillation, or if you're on heart medications, also corticosteroids. Those are all conditions in which experts say to reach for acetaminophen instead of NSAIDs. What about switching between different pain relievers, like when you have the flu or something? Is that okay? Yeah.

Short answer, this is okay for both kids and adults. Both Twegby, the pharmacist from UCSF, and Dr. Pasricha signed off on alternating between acetaminophen and NSAIDs with the caveat that you should always take the smallest amount that you need for the shortest interval possible to get the job done. And if you're not feeling better after a few days, Pasricha says certainly within three or four, talk to your doctor. Now, if you're in a lot of pain or you're treating a flu with a high fever, what should your schedule look like?

Pasricha says you still want to follow the guidelines on the back of the NSAID box, but if needed, it's okay to supplement with acetaminophen about halfway through. So let's say you take some Advil for aches and pains and fever at about noon. You're trying to hold off until 6 p.m. till your next dose, but at 3 p.m. your fever spikes. It's

it's okay to take a dose of Tylenol. And is the idea here that you just want to limit your use of NSAIDs as much as possible? Yeah, that's definitely part of it. But there's also been some recent research that alternating between acetaminophen and ibuprofen is a really effective pain relief method, especially for acute pain. I'm also wondering about combination pain relief meds like Excedrin or Midol PM. Where do they fit in?

with this conversation? Is there anything people should keep in mind before reaching for one of these? Mariel, I'm so glad you brought that up. I get migraines fairly often, and if I don't take Excedrin in time, I am completely out of commission. So this was a big question for me.

I asked Pasricha about this, and she had a couple of tips. The first, very similar to what she said at the very top of the episode, know what's in your medications and be very careful that you're not accidentally over-medicating yourself. And also, think about your specific health needs. Are you somebody who, you know, you take a daily aspirin every day anyway because of your heart health, and...

Think about that when you're grabbing an Excedrin and you have a headache. Are you already on a blood thinner? And now you're grabbing one or two more NSAIDs. You're putting yourself at a much higher risk than somebody who doesn't take a blood thinner every day anyway. So they're fine. They're good medications. They get the job done. But just try to be very, very careful that you know what is in the ingredients of everything that you're putting into your body. And the other tip she had here about NSAIDs was to be aware of your timing. Sometimes

people want to hold out on a headache or menstrual cramps. They want to, you know, ride it out, go the stoic route. But she says sometimes it makes more sense to take a small dose when you start to feel the pain. As opposed to now you're, you know, you've let two or three hours go by and

got this raging headache. Then the medicine has like a lot more catch-up work to do. And then I find that that's when people, they take that first dose. It doesn't work. So then, you know, half an hour later, well, let me just try one more dose. That doesn't work too. And then suddenly you end up taking more medicine than if you had just taken it at the start of the problem because it's just much easier to, you know, turn off the faucet than it is to plug a leak later. And that's sort of the situation people end up in. Yeah, that also sounds like it could be dangerous. Yeah.

You're absolutely right. You know, Mariel, when you're in a lot of pain, it can be really tempting to just throw whatever you've got at it. Maybe just pop a few extra Advil. But Pazricha says that's a really bad idea because depending on how you do it and what you're trying to treat, doubling down like that not only increases your risk of experiencing side effects, but it also won't necessarily provide you any more pain relief.

That's because NSAIDs have a ceiling effect. After which, you know, you've taken a certain amount of that medication and you're not actually getting any more bang for your buck. So she says she's seen patients come into the emergency room bleeding from an ulcer because they took too much pain medication. And probably whatever was causing the problem in the first place

So, you know, the takeaway here, as we've said, I feel about a million times at this point, talk to your doctor.

Talk to your pharmacist. Talk to your doctor early and often. Make sure the pain you're feeling can and should be treated with an OTC medication. And bonus tip from Pasricha here, if it does, you can always buy generic versus brand name pills because she says they will always have the same active ingredient. They have to. And they've gone through the same FDA approvals. So why not save yourself a few bucks? I guess it's worth saying here as we talk about painkillers that

Over-the-counter medication isn't the only option, right? There are things you can do that don't involve taking a pill. Yeah, Meryl. You know, the thing about over-the-counter medication is because it's so readily available, because it's so easy to reach for, often patients just don't even consider talking about what other options might be available for their back pain, their period cramps, their migraines, you know. But we have other ways that we can treat ourselves first when we're in pain, right?

If it's a migraine, maybe it's hot packs or cold packs, maybe a little yoga. And another option you might try, depending on what it is you're treating, topical pain medication. There are many NSAIDs available over the counter in cream, gel, or patch form. So you can pick up ibuprofen as a cream, for example. Sarunas mentioned diclofenac, popular for arthritis pain. And Pazricha mentioned capsaicin, which, fun fact, uses the spicy elements of chili peppers to help relieve pain. It's kind of like a fight fire with fire approach.

And while some of these may cause some skin irritation to some people, overall, Pasricha is a big fan of avoiding oral NSAIDs where you can and says topical NSAIDs can be really effective for pain relief. I think sometimes people just don't think to try it because it's way less common. But it's all there sitting in the drugstore for you. All right. Here's a question that I think comes up a lot for folks who have over-the-counter meds in their cabinet.

Yes, I am very guilty of this. I have done it a lot.

Twugby says, don't do it. Stop doing it. The active ingredient starts to degrade once the expiration date hits. And particularly with their expired prescription medications, you can now drop that stuff off at your local pharmacy and they'll dispose of it for you without you throwing it into the toilet and damaging the water system. But in terms of over-the-counter medications that are expired, do not use them. They're not going to help you.

So what Twigby says here is if this is something you've done before, you likely haven't harmed yourself if you've taken a painkiller that was a few months old. It just might not have been as effective as you'd want it to be. But it's still just not a good practice, not something you want to make a habit of. So check those medicine cabinets regularly. Do a sweep. Anything that's expired, take it to your local pharmacy.

Before reporting this episode, Mariel, I'll be honest, I would just toss old pills in the trash. Yeah, me too. But you don't want to do that for a couple of reasons. If you have any pets or small kids at home, that's a big safety risk. You wouldn't want any littles accidentally ingesting those expired meds if they somehow get into your garbage. And it can also be bad for the environment if those medications end up in your local landfill. So just bring them to your nearest drug take-back location or you can mail them using prepaid drug mail-back envelopes.

All right. Andi, thank you for looking into this. Thanks, Mariel.

Alright, it's time for a recap. Over-the-counter pain medications can be really helpful and effective, but remember they're not without risk, so aim to take the smallest amount you need for the shortest time possible to treat your pain. In general, acetaminophen works well for fevers, but you should steer clear of it if you've been drinking alcohol. And NSAIDs work better for pain plus inflammation. Think about a sprained ankle, for instance, but they can be hard on the stomach, so it's best to take them with food and be aware of any possible side effects. Think

Think about your lifestyle, chronic conditions, and other medications before you reach for an over-the-counter medication. Like, do you have a heart condition? Liver condition? Are you on a blood thinner? Understand any potential complications before you decide and don't stray from the directions on the box or bottle. Pharmacists are a great resource when you have questions about over-the-counter drugs. And if you find yourself continually reaching for an over-the-counter pain reliever, talk to your doctor.

For more Life Kit, check out our other episodes. We have one on sunscreen and another on what chemicals are in your personal care products. You can find those at npr.org slash life kit. And if you love Life Kit and want even more, subscribe to our newsletter at npr.org slash life kit newsletter. Also, we love hearing from you. So if you have episode ideas or feedback you want to share, email us at lifekit at npr.org.

This episode of Life Kit was produced by Claire Marie Schneider. Our visuals editor is Beck Harlan, and our digital editor is Malika Gharib. Megan Cain is our supervising editor, and Beth Donovan is our executive producer. Our production team also includes Margaret Serino, Sam Yellow Horse Kessler, and Sylvie Douglas. Engineering support comes from Kwesi Lee. I'm Mariel Segarra. Thanks for listening.

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