How To Use Over-The-Counter Pain Medications and Anti-Inflammatories: A Framework
As you might imagine, I am frequently asked about medications for pain and inflammation control. I find myself repeating the same framework, so consider this your cheat sheet when it comes to managing pain and inflammation.
The best part? This applies to just about any injury under the sun: a sprain, tendinitis, broken bone…even post-surgery (truly!).
The second best part? These are all available over the counter. No prescriptions, refills, long lines, or never-ending phone holds needed.
I will begin with the end (summary and examples) here for quick reference, but please be sure to continue on for the details and important safety concerns to look out for.
Suggested Protocol - “The 3 Cs”
Choose
Ibuprofen or naproxen are your two most likely choices. I prefer naproxen for ease and likelihood of success.
Commit
Once you’ve chosen, commit to taking a 7-10 day course of the NSAID, around the clock, whether you hurt or not in that moment.
This will maximize anti-inflammatory benefits and minimize side effect risks.
Don’t exceed 10 days. Stop if you notice any side effects. Always take with food.
Combine
NSAIDs and acetaminophen (Tylenol) do NOT negatively interact.
So take them together (if you need) to get the maximum benefit of their synergy.
This combination is as good or better than opioid prescription painkillers.
* Follow the bottle instructions of each individual medication for safety. Do NOT exceed the 24-hour limit of acetaminophen under any circumstance. Avoid alcohol while taking these medications.
*Ensure you haven’t been warned to avoid NSAIDs or acetaminophen by your primary care doctor. Do not take if pregnant, nursing, or a child.
Examples
The “I Like Pain Control, But I Like Sleep Better”
7 am: Take naproxen and acetaminophen with breakfast
1 pm: Take acetaminophen
7 pm: Take naproxen and acetaminophen with dinner
The “Night Owl With A Nasty Tendinitis”
6 am: Take naproxen and acetaminophen with breakfast
12 pm: Take acetaminophen
6 pm: Take naproxen and acetaminophen with dinner
12 am: Take acetaminophen
The “Post-Op But I Refuse Prescription Painkillers”
6 am: Take ibuprofen with breakfast
9 am: Take acetaminophen
12 pm: Take ibuprofen with lunch
3 pm: Take acetaminophen
6 pm: Take ibuprofen with dinner
9 pm: Take acetaminophen
12 am: If you’re up and really need it, take ibuprofen with a snack
3 am: If you’re up and really need it, take acetaminophen
The Opioid Bubble
It’s popped. Guys, it’s over. Opioids are out. No more news headlines about overdoses. It’s time to modernize our pain control.
Multiple recent studies have shown that over-the-counter NSAIDs (see examples below) with or without Tylenol medications are equally or more effective for pain control relative to opioids [1] [2].
I don’t understand why this is still a discussion. As a society, we can do this. It’s time to say goodbye to opioids forever.
Everything Has Risks
Big caveat: No medicine is completely safe. Even over-the-counter medications. ALWAYS follow the directions on the bottle. NEVER take a medication your primary care doctor has told you to avoid. A couple of specific points to highlight:
NSAIDs: NSAIDs are a class of medications known as Non-Steroidal Anti-Inflammatories. There are lots of medications in this class, but common ones would include ibuprofen (brand name Advil or Motrin), aspirin (brand name Bayer), and naproxen (brand name Aleve). While these medications can be total game-changers for managing pain and inflammation, they have side effects about which you must be aware.
This class of medications can be tough on your stomach and your kidneys. If you have any kidney problems, you will want to be clear about what your primary care doctor’s recommendations are regarding these medications. And anyone can develop stomach issues with these medications — the most severe form of which would be ulcers or stomach bleeding. ALWAYS take these medications on a full stomach and if you have had any history of stomach issues or reflux, be sure you have a clear understanding with your doctor about whether these are safe for you. And a final note. If you are pregnant, nursing, or under the age of 18, you must consult with your primary care doctor, pediatrician, or OB/GYN before taking these medications.
ACETAMINOPHEN (Brand name Tylenol): Acetaminophen is an interesting case. This drug is NOT an anti-inflammatory. Its role is to reduce pain and/or fever. We actually don’t fully understand how it works. In low doses, it is thought to be essentially harmless. But if you cross over a threshold of too much in a given 24-hour period, it can quickly become very toxic to your liver. Be sure you are following the recommendations on the bottle very carefully. I typically tell patients not to exceed 3 grams (3,000 milligrams) of Tylenol in any single 24-hour period.
The Good Stuff
Ok, those are the important precautions anyone must know when considering these medications. The vast majority of patients will be perfectly safe taking these according to the bottle instructions.
Let’s get to the good stuff. Here’s how to use these medications effectively:
Start with NSAIDs
If safe for you to take (see above), this is the best bang for your buck. They knock out both pain and inflammation. Hard to beat this 1-2 punch.
Choose The Right NSAID
When I ask the vast majority of my patients what they take, the response is ibuprofen (brand Advil, Motrin). This is a great strategy for acute pain, but it sort of misses the larger point.
The reason for this has to do with half-life. We could go into all kinds of boring science here, but to keep it easy, the half-life is an indication of the amount of time a given drug stays in your system before your body filters it out.
The half-life of ibuprofen is very short, somewhere around 2 hours. What that means is 2 hours after you take it, half the medication is already filtered out of your system. To maintain effective levels of the medication in your bloodstream, you have to take ibuprofen frequently (every 4-6 hours). This is inconvenient during the day and near impossible at night. It’s also expensive.
A Better Way
So here’s what I recommend instead. When dealing with pain or inflammation, consider naproxen (brand name Aleve). Naproxen has a half-life of about 15 hours!
That means you need to take it twice a day, max. This is much easier to do and is more likely to remain at peak levels of effective treatment in your bloodstream for longer. Rather than feeling the pain relief and anti-inflammatory effects intermittently, like the up-and-down roller coaster ride of ibuprofen, naproxen will sustain the effect over a long period of time.
What the up-and-down levels of ibuprofen would look like if measured in your bloodstream. Notice the momentary peaks, rather than sustained maximum benefit.
A Pact With Yourself
When taking naproxen for pain or inflammation, pre-commit to a period of time. I usually recommend you make the decision to take naproxen around the clock for 7-10 days. Don’t go longer than 10 days or you may begin to feel some stomach side effects.
But for the short period of time you choose, take the naproxen once every 12 hours, whether you feel pain or not. This will build a sustained level of anti-inflammatory, pain-killing magic in your blood that will work to relieve your condition…from the inside out!
Synergy Is Power
Now the real fun starts. If your naproxen strategy is helping but not as much as you’d hoped, harness the power of synergy and add acetaminophen (brand name Tylenol) to the mix.
NSAIDs and acetaminophen do not negatively interact, so you can take them at the SAME time. Or you can overlap. Whatever works for your schedule.
But if you take naproxen (or ibuprofen or your NSAID of choice) by the instructions on its bottle, and then also take acetaminophen by the instructions on its bottle, you will be getting the benefit of synergy between these medications.
This is the exact combination that was shown in the studies listed above to equal or exceed the power of potentially dangerous opioid prescription painkillers.
Wrapping It Up
Remember, these guidelines are meant to help you use these medications safely and effectively. If you have any questions or concerns, don't hesitate to reach out to us.
Any intervention in medicine, including over-the-counter medications, has its own risk vs benefits profile. Hopefully, this helps you better understand your options.
And remember that medications are one small piece of the puzzle to getting you well. You’ll want to combine with ice, heat, massage, and immobilization (see my bracing framework here) for the quickest path to relief.
Your well-being is our priority, and we're here to support you as you recover from your upper extremity condition.
References:
[1]: Friedman BW, Dym AA, Davitt M, et al. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015;314(15):1572–1580. doi:10.1001/jama.2015.13043
[2]: Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017;318(17):1661–1667. doi:10.1001/jama.2017.16190
