Which over the counter pain medication is best for me

Here at Nightlight Chiropractic, we get a lot of questions from patients about which over-the-counter pain medication is best for neck pain, back pain, and headaches. If you think about your medicine cabinet at home, it is chock-full of all kinds of substances. How do you pick which one you take? Is it just trial and error? Is it based on what your mom told you to do or what one of your parents told you to do a long time ago? Is it based on what your friends say is best to treat pain or certain conditions? We can clear this up for you, but first, let’s review what your different options are and discover why they might be the good or bad choice for what you have going on.

When we’re talking about over-the-counter pain relievers, all they’re doing is treating the symptom of pain. Pain is a symptom of something else going wrong in your body: some haywire misconnection of nerves or chemicals in your body that are signaling as pain, or more frequently, real tissue damage. The actual feeling of pain that we experience comes from something called the arachidonic acid cascade.

I’m going to try and keep this as non-chemistry as I can because the chemistry is really complex. It’s really, really difficult to understand kind of how this arachidonic acid breaks down into all these other enzymes and chemicals that then fuel pain and the different reactions that happen. It’s not one or two-step process. There are thousands of processes going on all at the same time. To keep track of each piece and chemical can become a nightmare.

Arachidonic acid is the fuel that then breaks into all these different enzymes. These enzymes then tell your body, “we need to create inflammation, we need white blood cells mobilizing to the area, we need to tell the brain that there’s pain going on, we need to add some extra fluid and some edema over here!” And this is all just as a result of some either real or perceived injury to tissue. Pain killers contain chemicals that block different parts of that arachidonic acid cascade. That’s it. End of the chemistry lesson.

Now let’s talk about over the counter pain medications. At Target, this aisle called “pain relief,” and it’s full of chemicals and medications. If I can’t navigate that and I kind of know what I’m doing, how is the general consumer supposed to navigate that? You might just close your eyes and grab something because you need something, you’re in pain. You have this huge aisle full of stuff, and it really boils down into two main groups of over-the-counter pain relievers that we have here in the United States, NSAIDs, and Acetaminophen.

First, let’s talk about non-steroidal anti-inflammatory drugs (NSAIDs). Steroids reduce inflammation and effectively, but steroids have all kinds of bad side effects, which is why they’re not available over-the-counter here in the United States. Instead, we have these non-steroidal anti-inflammatories, and what these do is to block part of that production cycle of cytokines and prostaglandins, which are the chemicals at the end of the arachidonic acid cascade. They help not only with pain but also with inflammation and swelling.

When we talk about tissue injury, we sometimes talk about secondary tissue injury that happens. You sprain your ankle, and then all of this fluid and all these white blood cells go to the area. And what ends up happening is, they block all the red blood cells, so you end up getting more cells that die as a result of all of that stuff that’s in the way. NSAIDs like ibuprofen do a great job of blocking the swelling and inflammation that happens so that you don’t get some of that secondary injury.

But there’s a problem with these guys. They have a really bad track record. Everywhere you go, you’re going to find an entire aisle full of these pain-relieving products, and they end up killing about 16,000 people per year. Sixteen thousand people here in the United States per year end up dying of these NSAIDs! We’re not talking about overdoses: this is not somebody is trying to take the wrong amount of these, this is not because somebody didn’t know what they were doing and just took a handful of them. This is people who are taking NSAIDs the way that the bottle says to take them, except they don’t stop when they’re supposed to stop.

NSAID bottles like Motrin (ibuprofen) and Aleve (naproxen sodium) tell you that if you are taking them for more than a couple of weeks, you should go back to your doctor and try and figure out what’s causing the symptoms. But I know plenty of people who take this stuff every day for decades. That’s what ends up causing 16,000 people per year to die. That’s the 15th leading cause of death here in the United States… What!? The 15th leading cause of death in the United States is people taking this over-the-counter medication correctly, not opioids, not any illicit drugs. These are things that we are told that we can take to manage swelling and inflammation and pain, and people are just continuing to take them for a long time until they end up with issues.

So how do these things end up actually killing you? It’s not instantaneous. You don’t just take two or three, and then suddenly, you keel over and die. They do a couple of different things. They cause gastrointestinal bleeding, so your gastrointestinal system ends up starting to have this ulceration. It ends up having these holes cut into it, and then over the long term that ends up being a big complication. Bleeding goes from your stomach, from your intestines, and then it causes complications, and then you end up passing away from it in the hospital. The other way that NSAIDs cause injury or death is by increasing your risk of heart attack and stroke.

A few years ago, there was something called Vioxx, a prescription pain medicine that’s a COX-2 inhibitor. These are very specific NSAIDs that only block one little piece of that arachidonic acid cascade. By blocking that one little piece, they can be a little bit more specific about how they do their job, but here’s the problem. Vioxx increased the risk of heart attack and stroke so much that it got pulled off the market very, very quickly because it was causing so many deaths. Celebrex is still out there as a COX-2 inhibitor that has been shown to be safer and has a similar profile to NSAIDs. Even though COX-2 drugs are a go-to for sprains and strains and muscle aches and backaches, there is a real risk to them.

If you’re taking any of the substances found in the pain relief aisle in Target, you need to make sure that you’re using it like it’s supposed to be used, which is a couple of weeks at a time. After that, if your pain is not gone, you have to figure out plan B, whether it’s visiting a chiropractor, going to your medical doctor, or something else. Your plan cannot be just continuing to take an NSAID again and again and again forever. They block pain, they block inflammation, but they also increase your risk of heart attack, stroke, and gastrointestinal bleeding. It’s much worse in the elderly than in younger patients. Even still, if you’re a younger patient now, you don’t want to be still taking this stuff ten years from now because you are going to be that older patient then who’s at risk.

In order to reduce your risk of ulceration of the stomach lining with NSAIDs, you might want to take omeprazole, which is an over-the-counter proton-pump inhibitor. It’s made for acid reflux and can help you reduce the NSAID-related ulceration of your stomach lining. Also, remember to take all NSAIDs with food.

The second type of over the counter pain reliever in the US is acetaminophen, also known as Tylenol, and it’s also in Excedrin. Acetaminophen works slightly differently on that arachidonic acid cascade that’s blocking different enzymes that create pain. It’s simply blocking prostaglandins that create pain, and it’s not going to do anything for the swelling and inflammation.

So, how do you choose? If you have a headache, acetaminophen might be a good go-to, and it’s much less risky than NSAIDs. The risk with acetaminophen is that the therapeutic dose and the overdose dose are pretty darn close to each other. You really want to make sure you’re following the instructions on this to a T, and you’re not taking it with alcohol. How about a hangover cure? Tylenol is probably not your best choice for that because it’s blocking pain, not blocking inflammation.

I prefer more natural methods of pain relief, like fish oil, turmeric, and ginger. These spices reduce inflammation without side effects. Read more about my natural recommendations for pain relief here (link to natural remedy blog). I hope this article has helped you make smarter choices next time you have a headache or muscle pain.

About Dr. Merrill

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Dr. Andrew Merrill is a passionate active clinician and owner of Nightlight Chiropractic Orlando where him and his team treat hundreds of patients each month. With a strong background in exercise science from Stetson University, clinical skills from Palmer College of Chiropractic, and continued postdoctoral training in spinal disc injuries and clinical nutrition, Dr. Merrill is very well versed in the healthcare landscape. With topics ranging from "what to do for common ailments" to "why the medical system is failing you" Dr. Merrill and this blog in particular aim to keep readers up to date on what the research shows and how you can put it into practice NOW to keep yourself healthy for a lifetime.