Pain Medications

• What Is Pain?
• Nonsteroidal Anti-Inflammatory Drugs
• Acetaminophen
• Acetaminophen Combinations
• Narcotics
• Abuse, Addiction, and Withdrawal
• Pain Medications to Avoid
• Synonyms and Keywords
• References
• Authors and Editors

What Is Pain?

Pain is an unpleasant sensation. Pain can be sharp or dull, burning or numbing, minor or major, acute or chronic. It can be a minor inconvenience or completely disabling.

Both the area of the injury and how the brain deals with signals from the area of pain affect the sensation. Generally, medications try either to stop the transmission of pain from the site of injury or to affect the brain directly.

The effects of pain medication are different for different people. Also, the tolerance of pain varies greatly from one person to another.

For this reason, one medication will not be right for everyone with the same injury. For example, some people are quite happy with an over-the-counter medication for an ankle sprain, while others will need a more powerful prescription pain reliever. The right pain medication depends on the person experiencing the pain, not on the condition that is causing the pain.

Nonsteroidal Anti-inflammatory Drugs

The most common nonsteroidal anti-inflammatory drug (NSAID) for pain is ibuprofen. Three NSAIDs are available for purchase without a prescription in drug and grocery stores:

Naproxen

• Aleve

Ibuprofen

• Advil
• Children's Advil
• Children's Motrin
• Excedrin IB
• Midol 200
• Motrin IB
• Nuprin
• Pamprin IB

Aspirin

• Anacin
• Ascriptin
• Aspergum
• Bayer Aspirin
• Bayer Buffered Aspirin
• Bayer Low Adult Strength
• Bufferin
• Ecotrin
• Empirin
• St Joseph Adult Chewable Aspirin

Essentially, aspirin and ibuprofen are short-acting, while the effects of naproxen last longer. This difference means that sometimes it takes three to four doses of naproxen before an effect is noted. Because of this difference, it may be better to use ibuprofen for more immediate relief from pain and to use naproxen for long-lasting relief.

Many NSAID medications are available only with a prescription. These include the following:

• fenoprofen (Nalfon)
• flurbiprofen (Ansaid)
• ketoprofen (Oruvail)
• oxaprozin (Daypro)
• diclofenac sodium (Voltaren, Voltaren-XR, Cataflam)
• etodolac (Lodine)
• indomethacin (Indocin, Indocin-SR)
• ketorolac (Toradol)
• sulindac (Clinoril)
• tolmetin (Tolectin)
• meclofenamate (Meclomen)
• mefenamic acid (Ponstel)
• nabumetone (Relafen)
• piroxicam (Feldene)

This class of drugs is one of the most marketed types of medications by drug companies. No clear evidence exists that the prescribed medicines costing a dollar a pill or more are any better than those that cost less than a penny a pill.

Different NSAIDs are also marketed as being better for certain conditions. An example of this is indomethacin (Indocin) as a recommended treatment for gout. There is no proof that this holds true, but some evidence shows that different families of NSAIDs may have a selective effect on a person-to-person basis.

The main side effect of these types of medicines is that they can cause bleeding in the stomach. This bleeding usually occurs after long-term use but can also occur with short-term use. Long-term use can also affect the kidneys. For these reasons, acetaminophen is probably much safer for long-term use, although taking too much acetaminophen can cause liver or kidney damage. When you take pain medication, be sure to check whether it contains acetaminophen so that you do not take more than is recommended by mistake.

NSAIDs have both a pain-relieving and inflammation-stopping effect. Generally, the pain-relieving effect does not increase with higher doses; thus, 400 mg of Motrin has just as much pain relief as 800 mg of Motrin. A person is more likely to suffer a significant stomach problem with the higher dose.

• Consult a doctor if a person taking NSAIDs experiences pain in the stomach, has black stools, or has blood in the stool.

A new NSAID: Cox-2 inhibitors

• Long-term use of NSAIDs can cause bleeding in the stomach. In response to this, the drug industry has produced a new class of NSAIDs, the COX-2 Inhibitor.
• Presently, only celecoxib (Celebrex) remains on the market. Valdecoxib (Bextra) and rofecoxib (Vioxx) were voluntarily withdrawn from the market because of an increased risk of heart attack, stroke, and severe skin toxicity (see below).
• Because these medications have been on the market for only a short time, the long-term side effects are just now beginning to be understood. These medications have not been proven to be stronger than ibuprofen, acetaminophen, or naproxen. It is also unclear whether these medications cause less significant stomach problems.
• People older than 75 years are at more risk of significant stomach problems, such as ulcers, from NSAIDs, especially if they have had previous ulcers. Elderly individuals also typically have higher risk factors for heart attack and stroke.
• Alert: On September 30, 2004, Merck & Co, Inc, announced a voluntary withdrawal of the COX-2 inhibitor, rofecoxib (Vioxx), from the US and worldwide market because of its association with an increased rate of cardiovascular events (including heart attacks and strokes) compared to that of placebo. A major US Food and Drug Administration (FDA) study of rofecoxib found an apparent 3-fold increase in the risk of sudden cardiac death or heart attack among patients who had taken higher doses of the drug compared to the risk of patients who had not recently received similar medication. The report showed that even patients taking the standard starting dose of 12.5 mg or 25 mg of rofecoxib had a 50% greater chance of heart attack or sudden cardiac death than patients on any dose of celecoxib (Celebrex). The large-scale study was conducted after analyzing the medical records of 1.4 million people insured by Kaiser Permanente in Oakland, Calif, between 1999-2001.
• Alert: On April 7, 2005, valdecoxib (Bextra, by Pfizer, Inc) was voluntarily withdrawn from the US market, pending further discussion with the FDA. The association of valdecoxib with potentially life-threatening risks, including myocardial infarction, stroke, and serious skin reactions, initiated an investigation to determine whether the benefits of the drug outweighed the risks. The serious skin reactions are most likely to occur in the first two weeks of treatment, but they can occur at any time during therapy. Valdecoxib should be discontinued at the first sign of rash, mouth sores, and/or allergic reactions (for example, swelling, itching, shortness of breath). Other COX-2 inhibitors and traditional NSAIDs (for example, naproxen [Aleve, Naprosyn], ibuprofen [Motrin]) also have a risk for these rare, serious skin reactions, but the reported rate of the reaction appears to be greater for valdecoxib. New data regarding risks in individuals who take valdecoxib following heart bypass surgery showed an increased risk of heart attack, stroke, deep vein thrombosis (blood clots in the leg), and pulmonary embolism (blood clots in the lungs).
• Celecoxib (Celebrex) remains on the market and appears to have the same cardiac risk profile as does ibuprofen.

Besides COX-2 inhibitors, other options exist to protect the stomach from ulcers and bleeding associated with NSAIDs. The additional use of misoprostol (Cytotec) or a proton pump inhibitor, such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium), with an older NSAID may decrease ulcer formation and bleeding.