Using Aspirin and its Colleagues  (April 23, 2019)

It should be emphasized here, right out of the gate, that medications are just one of many methods that can be used to relieve pain. Moreover, they are usually one of the less desirable because their effects are temporary and compared with the alternatives, they don't do all that much for you. These alternatives are umpteen different styles of therapeutic exercise, biofeedback and other therapies (in particular cognitive behavior therapy, mindfulness and meditation), plus passive treatments like chiropractic and acupuncture and massage, that not only relieve pain but make helpful and healing changes in your body and mind as well.

So although we don't think of them that way, medications are really a poor cousin to other pain-relieving therapies. If you have chronic pain, you will have to find which therapy, or which combination of them, works best for you. There is no substitute for that. But while you are finding that out, plus in a very few other cases, there are OTC (over-the-counter) painkillers. 

Don’t let America’s recent love affair with opioids fool you. Cheap, generic, easily accessible OTC painkillers (sometimes in combination with each other or other non-opioid meds) not only relieve pain as well or better than opioids do in the majority of cases, they can handle problems (like inflammation and fever) that opioids cannot. That is one reason that doctors are quietly beginning to prescribe them again. Their use has been neglected in favor of their flashier cousins for well over 20 years now, and it is about time they had a few moments in the sun.

So if it happens that a painkiller is indicated, which one? THAT just so happens to be my subject today. What a coinky dink! 

OTD pain relievers break down roughly into two categories: acetaminophen and NSAIDs (non-steroidal anti-inflammatory drugs). Meaning acetaminophen on the one hand. and everything else on the other. Acetaminophen can be rough on your liver, whereas NSAIDs tend to give more stomach problems, but not everyone has those issues with them, and unless you get major side effects with one or the other, that's not the way to choose which one to use.

Acetaminophen or paracetamol (“Tylenol”, etc.). Acetaminophen is the world’s most widely used painkiller, partly because it is a REALLY good painkiller. It’s used to treat cancer and post-surgical pain and sometimes even given intravenously in emergency rooms. It works great on pain from muscle cramps (but not the cramps themselves; you need NSAIDs for that). (Opioids, incidentally, work best on pain from wounds and cut tissue, which is why they are still the stars of post-surgical pain treatment. But they don’t work on cramping or inflammation. They kill pain in the short run, and that’s about it.)

Acetaminophen does not reduce inflammation or swelling. It sort of reduces fever, but it’s not the first thing you’d use if fever is the biggest issue. Interestingly, it is not known exactly how acetaminophen works, but don’t let that spook you – we didn’t know how aspirin worked for ages and used it effectively anyway. There’s more that’s unknown in medical science than anyone wants to admit. 

Using acetaminophen with caffeine improves its efficacy at least some of the time. You can also use it with ibuprofen safely (depending on what the labels say). It doesn’t irritate the stomach and it doesn’t thin the blood. If all you want to do is a little pain relief, acetaminophen is probably your girl. Don't forget to READ THE LABEL FIRST.

NSAIDs relieve pain, but also fever and inflammation (depending on the NSAID, some more, some less). So you can think of them as a bit more potent than Tylenol. Pain from swelling and inflammation is what these work best on. They work on only about 60% of the population, but if one doesn’t help, another one might, so if you really need one, don’t give up on them too fast.

They can also irritate the stomach, which apparently is the reason why the powers that be are so set against aspirin, since of all of them, it's the one that's most irritating to the stomach. The common OTC NSAIDs are

Ibuprofen (Advil, Motrin, etc.). It treats pain like acetaminophen, treats fever better than acetaminophen, and unlike acetaminophen is an anti-inflammatory (although weaker than the other NSAIDs). It’s also good for pain from muscle cramping and for the cramps itself, which you get after a lot of medical procedures and related to the menstrual cycle.

Naproxen sodium (Aleve) is another NSAID. It relieves pain and fever and is good for muscle cramps and the pain from them as well.

Aspirin. You can read an entire article on the internet these days that supposedly discusses over-the-counter pain relievers without a word about aspirin. Which is sick, because aspirin treats pain, inflammation, and fever better than any of the other OTC NSAIDs. Plus, unlike the other NSAIDs, which can cause problems with the cardiovascular system, it is actually used in the treatment of cardiovascular disease and is helpful in the prevention of more than one cancer.

So why all the hate? Oh yeah, it might upset your stomach. So if it does, take something else. How hard is that? But keep in mind that in older people especially, who can use both pain relief AND the positive cardiovascular effects of aspirin, it would be stupid to not even give aspirin a shot.


The different effects these have, plus the other non-opioid medications available for pain (which include the gabapentoids, corticosteroids, and even antidepressants) individually or in combination, give any doctor who is paying attention a very effective set of tools to use on pain. Not to mention the other treatments I listed above.

Because there are always going to be people who’ll need prescription painkillers to help them function. But there are not nearly as many of them as was assumed just a few years ago. And they will be treated less and less often with opioids and more and more often with other meds plus other therapies, which is the way it should always have been. 

People want a quick solution to their pain – and the more pain, the quicker they want it. Doctors, with little understanding of pain or ability to treat it, wanted the same thing. Insurance companies were right there with the doctors (and make sure that you add  “cheap” to what THEY want). And pharmaceutical companies were glad to indulge everyone. So we got the opioid epidemic. 

We never needed a flood of opioids. So do not mourn, or fear, their departure. There will be a little more work, for a lot more reward, to achieve good pain relief now. We will all be better off for it. 

--dr. diane holmes
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