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Health Matters: Options for non-prescription pain relief

Conway McLean, DPM, Journal columnist

Let’s face it: all pharmaceuticals have the potential for complications. As integral a part of everyday life as they are, pharmaceuticals can cause problems. Even when used appropriately, per FDA instructions, problems can occur with many medications, often the result of ongoing use.

Some of the highest medicinal sales are for over-the-counter pain medicines. Orthopedic pain is especially common, and something most everyone deals with at some point in their lives. Pain may be experienced from some minor trauma, a turned ankle or a stubbed toe. An ice pack or two, a couple of aspirin, and good as new. We’ve all heard the cliché “Take two aspirin and call me in the morning!”

Aspirin was once considered a miracle drug and it remains one of the most widely used drugs in the world. Some of the underdeveloped countries don’t have access to more “modern” drugs like ibuprofen (the first example of a true non-steroidal anti-inflammatory drug) and so aspirin remains in everyday use. Older than ibuprofen is acetaminophen, known in Europe as paracetamol. This drug has been in use for nearly a century and a half. Many consider this the most widely used drug worldwide, although accurate statistics are impossible to obtain.

In the United States, we have numerous options for pain relief, when considering both prescription and over-the-counter options, at least so it would appear. The aisle devoted to pain relief spans a great distance at your local national pharmacy chain. And yet, upon more detailed examination, it boils down to a few simple choices. All the various brands and formulations all come down to three options for pain relief. Those products depending on acetaminophen, and there are a multitude, those containing a non-steroidal anti-inflammatory (usually ibuprofen), or aspirin. Which is better? How does one choose?

Aspirin has a long and successful history, dating back over three thousand years, although it was in the form of willow bark. This was used as a painkiller by ancient Egyptian cultures from antiquity, and then by physicians from ancient Greece and Rome. The primary component of aspirin is a chemical known as a salicylate, discovered in 1763 because of its ability to lower fever. Numerous researchers were involved in the on-going study of these chemicals with aspirin first synthesized by a chemist working for the Bayer company in 1897. Voila, the famous Bayer aspirin was born.

Acetaminophen was first synthesized by a researcher at Johns Hopkins University in 1877, but it was not administered to humans for another 10 years. Derivatives of this had previously been created but found to have unacceptable toxicity. There were concerns about paracetamol initially as well, which greatly delayed its introduction to the marketplace. Phenacetin, a similar compound, was tremendously popular at the turn of the 20th century, but numerous studies uncovered dangerous consequences from use. The early concerns about acetaminophen were found to be unfounded and the drug subsequently rose steadily in popularity and use to become the most frequently recommended pain reliever.

It would be inaccurate to say the newest is always going to be the best, but ibuprofen has also gained in popularity since its development. The chemists who discovered it were looking for an alternative to aspirin, which was known to have many gastro-intestinal complications (stomach and intestines). Developed in the 1950’s and patented in 1961, the drug became available by prescription in the US in 1974 and over-the-counter since 1984.

As the name implies, NSAID’s, ie non-steroidal anti-inflammatory drugs, reduce levels of inflammation. When there is acute inflammation, as after a sprain, this can be a positive effect. Surprisingly though, inflammation is part of the healing process in the human body, so these drugs are best used for only a limited time. Unfortunately, this is too often not the case.

There has been concern about the safety of NSAID’s for a number of years, and several of this group has been shown to increase blood pressure, largely through their effects on the kidney. The stomach problems associated with ibuprofen are well-documented and are a predictable consequence of prolonged use, ranging from stomach pain to bleeding ulcers. And with approximately 30 million people taking NSAIDs for pain relief daily, there are bound to be complications. Moreover, these drugs are responsible for potentially deadly gastrointestinal problems. Each year, the side effects of long-term NSAID use cause nearly 103,000 hospitalizations and 16,500 deaths.

Use of aspirin fell during the 90’s, partially due to the marketing efforts of the manufacturers of these newer products. Aspirin is extremely inexpensive to manufacture so it remains popular in many parts of the world. Here in the states, acetaminophen is the most widely used pain relief medication. It has also been considered one of the safest, although that belief has come into question. It is found in more than six hundred OTC and prescription medications, including Tylenol and Vicodin.

Aspirin, like every medication, has potential complications and side effects. The gastric problems of the NSAID’s are even more pronounced with aspirin. But the drug gained new life when it became recognized for reducing excess clotting of the blood, a milestone in preventing heart attacks and strokes. The aspirin story continues with growing evidence it has benefits in reducing the risk of certain types of cancer.

Quite often, one of the big three, acetaminophen, aspirin or ibuprofen, can be found in some preparation or product. From the common cold to aching muscles, concoctions for many maladies use one of these ubiquitous substances, be they prescription products or OTC. Paracetamol (acetaminophen) especially is used in products you might not suspect. Thus, because too often people are not checking the ingredients of these meds, they are ingesting significantly more of acetaminophen than they realize. When it is broken down in the liver, a substance is created which is dangerous to this essential organ. If enough of this substance is produced, the consequences can be deadly.

What is a person to do for pain? This is often not an easy answer. Unlike the NSAID’s, acetaminophen does not raise the risk of stomach or heart problems, making it a popular option for those unable to tolerate NSAIDs. For acute inflammation, as with post-operative pain, NSAID’s are beneficial for reducing swelling and stiffness. But these are medications meant for short term relief and continued pain means something else needs to be done.

There are many options for non-pharmacologic pain relief, from topical medications to electrical methods. Exercise therapy can do great things for orthopedic pain. But a reliance on pharmaceutical measures for pain relief will more often than not lead to complication. Learning about these issues is now easier than ever. Educate yourself about your options and the downside of over-the-counter pain relievers.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.

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