When you’re in pain—whether from aching joints, strained muscles, or a headache—the drugstore offers what seems like a vast array of options. Marketing and dosage aside, however, there are really only a few primary types of oral over-the-counter (OTC) pain-relief medications.
The two basic types are acetaminophen (such as Tylenol) and NSAIDs (nonsteroidal anti-inflammatory drugs). The nonprescription NSAIDs are aspirin, ibuprofen (such as Motrin and Advil), and naproxen (such as Aleve). All are available as generics, and all come with important cautions. These issues relate primarily to people who take pain relievers at least several times a week:
- Cardiovascular risk. Over the years, studies have linked NSAIDs to an increased risk of heart attacks and strokes, especially when taken long term, at higher doses, or by people who previously had a heart attack (or had cardiac risk factors). In 2015, the FDA toughened its warning about these risks for all except aspirin, based on a review of newer research. It added, among other things, that the risks include heart failure and that the risk of heart attack and stroke can occur as early as the first weeks of NSAID use.
- Blood pressure. NSAIDs can raise blood pressure. This may be at least partly responsible for the increased risk of heart attack and stroke. The evidence about acetaminophen is inconsistent.
- Gastrointestinal (GI) bleeding. NSAIDs can damage the stomach lining and cause bleeding and ulcers. This has long been considered their major drawback, as the labels warn. The risk is greatest in long-term users, those over 60, heavy drinkers, those with a history of GI bleeding or ulcers, and those taking certain medications, such as blood-thinning drugs or steroids.
- Liver damage. Acetaminophen does not cause GI bleeding, but long-term use or even large single doses can cause severe liver damage. Most people are unaware of this risk and don’t realize that acetaminophen is in hundreds of OTC cold, allergy, and headache products and some prescription pain relievers. Check labels for acetaminophen, and don’t take more than 4,000 milligrams a day from all sources. Alcohol and certain other drugs increase the risk. Heavy drinkers and those with liver disease should avoid, or at least limit, acetaminophen.
- Kidney damage. NSAIDs (and acetaminophen to a lesser extent) can damage the kidneys. If you have kidney disease, talk to your doctor about pain reliever safety.
For healthy people who take OTC pain relievers as directed, the risks are relatively small. Don’t let these concerns prevent you from taking the drugs if you need them, but do follow this advice, especially if you take pain relievers often:
- Try other treatments first. For arthritis or back pain, for instance, that means exercise, weight loss, topical NSAIDs, heat or cold therapy, and physical therapy.
- Talk to your doctor about which pain reliever is safest for you to take.
- Consider acetaminophen first, then naproxen. Acetaminophen is safest for the GI tract, though it may not provide enough relief, since unlike NSAIDs it doesn’t reduce inflammation. Contrary to some previous research, a study in The New England Journal of Medicine in 2016 found that the prescription NSAID celecoxib is similar to OTC NSAIDs in terms of cardiovascular safety.
- Take the lowest effective dose for the shortest time possible.
- Do not exceed the doses listed on the labels or take for more than 10 days, unless your doctor has instructed otherwise.