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The safest ways to stop pain

Worried about new warnings on pain drugs? What you need to know to get relief.

Published: January 2014

Open your medicine cabinet, your purse, your briefcase—chances are you’ll find at least one type of pain reliever there. From over-the-counter drugs for headaches and muscle strains to powerful pills prescribed to control pain after surgery, those drugs are everywhere. In fact, almost 80 percent of adults say that they take some kind of pain medication at least once a week.

But determining which pain drug we actually need, and how to use it, has become increasingly fraught. We’ve seen frightening headlines about many pain relievers, including some that you may have considered harmless. In 2012 the Food and Drug Administration proposed that labels on products containing acetaminophen, the active ingredient in Tylenol, carry stronger warnings saying that the drug could cause severe liver damage if users exceed the recommended daily maximum dose. Even before that announcement, the maker of Tylenol reduced the maximum daily dose on Extra Strength Tylenol to 3,000 milligrams from 4,000 milligrams, and increased the dose interval from 4 to 6 hours, amid reports of increases in accidental overdoses.

The news on prescription pain pills is even more worrisome. As prescriptions for powerful painkillers such as hydrocodone and oxycodone (Percocet, Vicodin, OxyContin, and generics) have shot up in recent years, there has been an increase in emergency-room visits and deaths from the illicit use of those drugs, known as opioids. Three-quarters of prescription drug overdoses (from which the death rate has more than tripled since 1990) are now attributed to painkillers. And there’s grow­ing evidence that those drugs are being prescribed when they’re not necessarily warranted, including for such conditions as acute infections and heart problems.

In spite of all this, the need for pain relief is real. When should you self-treat with OTC drugs? When are prescription pills war­ranted? And how do you balance the need to feel better with the fear of taking a drug that might be addictive? Here are six tips to help you choose the best treatment.

1. Don’t assume that over-the-counter equals safe

Acetaminophen is not the only nonprescription pain medication that merits caution. Take aspirin, for example. It has been available for more than a century, but “if it were introduced today, it would be a prescription drug,” says John T. Farrar, M.D., Ph.D., an associate pro­fessor of epidemiology, neurology, and anesthesia at the Hospital of the University of Pennsylvania in Philadelphia. As with other nonsteroidal anti-inflammatory drugs, or NSAIDs, aspirin blocks chemicals in the body that trigger pain and inflammation. But it’s also a powerful anticlotting agent (hence its use in the prevention of heart attacks and strokes), which makes it more likely than some other OTC pain relievers to cause gastrointestinal bleeding. So unless your doctor prescribes it for a specific reason, you’re better off using another NSAID, such as ibuprofen (Advil, Motrin IB, and generic) or naproxen (Aleve and generic). All work equally well against pain from arthritis and other causes.

2. Skip acetaminophen if you regularly drink alcohol

Even with the risk of an overdose, acetaminophen is generally considered safe if taken as directed. But that goes out the window when alcohol comes into the picture. Look at the label of any OTC acetaminophen product and you’ll see a warning that “severe liver damage may occur” if you drink three or more alcoholic beverages a day while taking it. And keep in mind that the number is based on standard beverage sizes. What many of us pour or are served at a bar or restaurant can be much larger.

3. Don’t take opioid painkillers for longer than necessary

As a rule, you should consider opioids such as hydrocodone and oxycodone only for situations of acute pain—after an injury or tooth extraction, for example—or if you have severe ongoing pain and other options haven’t worked. Even then, aim for the lowest possible dose for the shortest possible time, since all opioids can cause sedation, nausea, vomiting, and constipation, and can ultimately be addicting.

That said, some research has shown that only about 5 percent of people who take opioids for a year become addicted to them. And shorter periods of use appear to pose even less risk of addiction. Of course, there are other reasons to keep your use of the drugs brief. Their safety over long periods hasn't been well established, and a recent study found that the risk of developing depression increases significantly when opioids are used for more than 90 days.

Do alternative methods really work?


Here’s the lowdown on three nondrug therapies. (They’ve been studied mostly in people with lower-back pain.)


ACUPUNCTURE A review of 32 studies found that this technique—in which needles are inserted at points in the body associated with pain perception—reduced back pain. But the studies were often poorly designed and are difficult to compare. Complications are “rare and transient,” according to one study, but can include infections.


Average cost $66 per session.


CHIROPRACTIC A 2013 study published in the journal Spine found that this therapy, in which a practitioner manipulates the spine, was no better than a placebo treatment in relieving lower-back pain. but in a 2011 survey Consumer Reports subscribers found it helpful. A large British study found that the risk of serious problems was “low to very low,” but there have been reports of occasional major complications, from pinched nerves to stroke.


Average cost $71 per visit.


MASSAGE It relieved back pain better than a placebo in a recent review of studies, but the studies had some flaws and the results may dissipate soon after treatment. Massage was not necessarily better at relieving pain compared with conventional therapies. If you have any health issues, such as osteoporosis, check with your doctor to see if massage is appropriate.


Average cost $60 per hour.


4. Be careful even with nonaddictive prescription pills

Prescription-strength NSAIDs are first-line agents for what’s called nocicep­tive pain—when an injury such as a deep cut or a burn sends pain through nerve endings. Even in relatively high doses, those drugs don’t pose a risk of de­pendency. And drugs prescribed for widespread nerve-related pain due to diabetes or fi­bro­myalgia—such as the older anti­de­pressants amitriptyline and nortriptyline, the newer antidepressant du­loxetine (Cym­balta and generic), and the antiseizure drug gabapentin (Neuron­tin and ge­ner­ic)—generally aren’t habit-forming. But duloxetine can increase the risk of bleeding if used with NSAIDs or aspirin, and stopping it may cause dizziness, headaches, insomnia, or anx­iety. Gabapentin can cause weight gain, back or joint pain, depression, or extreme fatigue. Suicidal thoughts can be a side effect of both drugs.

5. Don’t combine the same type of pain relievers

But mixing certain types might be OK, experts say. For example, say you have a splitting headache and took Tylenol, but it’s not helping. Try taking a dose of naproxen. The two drugs work differently and have different side effects, so you won’t double the possible risks by combining them. But avoid mixing two of the same kinds of medication—such as taking ibuprofen when you’ve already taken the similar drug naproxen.

Photo: Diamond Sky Images

Ice or heat? Which to use.


Apply ice immediately (but not directly on your skin) for up to 20 minutes, three to four times a day, after an acute injury. This will reduce blood flow, swelling, and inflammation. Also rest and elevate the affected area. After 24 to 48 hours, if inflammation has subsided, you can switch to heat, which helps relax muscles and improves healing circulation.


6. Read the label, always

It might not be obvious from the name on the package which drugs are in a product. For example, you might not realize that hundreds of OTC cold-and-sinus medications contain a pain-relieving and fever-reducing ingredient, usually acetaminophen, in addition to a decongestant. So if you take, say, a cold-and-sinus product and then take Tylenol PM (which contains acetaminophen in addition to a sleep-inducing antihistamine) to help you sleep, you might exceed the daily limit of acetaminophen.

A guide to common pain relievers

 

Use the information in this chart on your next trip down the pain-relief aisle at the drugstore, or to guide your next conversation with your doctor about pain relief. You can find more free information on these and other pain drugs at CRBestBuyDrugs.org.

Drug or drug class  What it works for Risks Considerations
Over-the-counter      
Acetaminophen Mild to moderate pain, including headaches and osteoarthritis.  Taking more than 4,000 mg a day or mixing it with alcohol can harm the liver. 

Not as effective as NSAIDs such as ibuprofen and naproxen for most pain, but it’s gentler on the stomach.

NSAIDs ibuprofen, naproxen*

Mild to moderate pain such as headaches, migraines, osteoarthritis, and muscle aches.

Can cause stomach and intestinal bleeding. Long-term use increases the risk of heart attack, stroke, and kidney damage.

Avoid NSAIDs if you’ve had a heart attack or stroke, you take aspirin for heart protection, or you have kidney disease or high blood pressure. and don’t take them for more than 10 days without consulting a doctor.

Topical analgesics camphor, capsaicin, menthol, methyl salicylate 

Muscle strain or joint pain from osteoarthritis.

Adhesives on patches might cause allergic reactions, and some people have reported getting skin burns.

There’s little research on how well OTC topical pain relievers work. But don’t use them with heating pads because the combination can cause burns. 
Prescription      
Opioids hydrocodone, morphine, oxycodone, and others 

Best used for acute pain, such as after surgery or trauma. Also available in fast-acting versions for cancer pain.

Side effects include sedation and nausea. Opioids can be addictive and can cause impaired immune function and greater pain sensitivity. 

They’re only moderately effective in treating long-term chronic pain and should be used as a last resort in those cases. The effectiveness can diminish over time. They shouldn’t be used to treat migraines, nerve pain, or fibromyalgia.

Celecoxib (Celebrex)

Osteoarthritis pain in people at higher risk of gastrointestinal side effects.

Some risk of stomach irritation, and might pose cardiovascular risks, especially at higher doses.

Celecoxib is no more effective at relieving osteoarthritis pain than ibuprofen or naproxen, according to our recent Best Buy Drugs analysis. But it has a lower bleeding risk.

Muscle relaxers baclofen, cyclobenzaprine, and others

Relieve back and neck muscle spasms and “spasticity.”

Sedation, fatigue, and dizziness, and some risk of addiction. 

It’s better to treat common neck and back pain with ibuprofen or naproxen first. There’s no evidence that muscle relaxers work better than NSAIDs for such pain, though they can be helpful for spasms.

* Aspirin generally isn’t recommended for pain relief because it’s less effective and more likely to cause bleeding than ibuprofen, naproxen, and other NSAIDs. Source: Consumer Reports Best Buy Drugs

Is that pain pill safe?

Even though I closely follow health news, it was a shock to learn just how easy—and common—it is to overdose on acetaminophen, a drug I’ve taken to stop my headaches since I was a child. More than 78,000 people end up in U.S. emergency rooms each year, and hundreds die, from either intentionally or accidentally taking too much acetaminophen, which can damage the liver at doses exceeding 4,000 milligrams a day. (That’s the amount in just eight Extra Strength Tylenol pills.) In fact, it’s the country’s leading cause of liver failure.


Why is it so easy to overdo it with acetaminophen? One reason is that it’s in such an astonishing array of products. No fewer than 600 prescription and over-the-counter drugs contain it, including cough syrups, multisymptom cold and flu medicine, and sleep aids. Take, say, a few doses of Tylenol throughout the day for a headache, then a cold and flu medicine in the afternoon, and an OTC “PM” sleeping pill containing acetaminophen at night, and you could easily ingest more than the daily limit.


Getting pain relief is important. But the key is to do it right, from carefully checking labels and dosage instructions to understanding the potential risks and side effects.


The chart above is designed to help you do just that. If you find it useful, or have a question, send me an e-mail.  


—Jamie Kopf


Editor's Note:

This article appeared in the February 2014 issue of Consumer Reports on Health.



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