Over the counter (OTC) pain medications or prescribed non-steroidal anti-inflammatory (NSAID) medications are often the best first option that doctors advise patients to use when addressing acute, nonspecific pain issues, osteoarthritis, or musculoskeletal pain. Especially with the new research supporting that there is no difference in pain management between opioids and NSAIDs, doctors have more reason than ever to use more conservative management for pain related complaints1. Even so, with so many over the counter (OTC) and prescription pain relief options out there, how is anyone to know what to choose and how much to take? Here, we break down the when and why of some of the most common NSAIDs and other common pain relievers.
Used as an analgesic (pain reliever), anti-inflammatory, or anti-pyretic (fever reducer). They are commonly used for musculoskeletal pain, OA, rheumatoid arthritis, menstrual pain, fever, headache, or toothaches. They are generally broken down into groups based off of their inhibitory mechanism of action on the enzyme, cyclooxygenase (COX): COX1 selective, non-selective, and COX2 selective NSAIDs. Dosing is dependent on the specific drug and what it is being used for, as higher doses of NSAIDs are required for anti-inflammatory effects when compared with the lower doses required for pain management 2.
COX1 selective NSAIDs, such a ketorolac, have higher incidences of gastrointestinal (GI) side effects and are not commonly a first line agent for pain relief. Selective COX2 inhibitors, such as Celebrex, though do not affect the GI system, they increase the risk of cardiovascular events and thus must be used with caution in patients with known cardiovascular disease (CVD) or who are at higher risk CVD development.
Most non-selective NSAIDs have identical analgesic effects and they are mostly selected for use based on cost and side effect profile 2. Ibuprofen (Advil, Motrin) and naproxen (Aleve) are two common OTC whereas diclofenac and meloxicam are examples of prescription NSAIDs, all of which are non-selective in nature. Diclofenac and ibuprofen are available in topical formulations and have been shown effective for musculoskeletal complaints and have lower side effect profiles because of their lack of systemic effects 3.
Aspirin is also considered a non-selective NSAID, however its effects on the COX enzymes are irreversible, and thus not commonly used as a pain reliever due to side effects.
All NSAIDs can affect kidney function and must be used with caution. There is also a risk of severe allergic reaction, so patients are advised to discontinue any NSAID use if they experience swelling of the lips or tongue or experience trouble breathing. NSAIDs are also not safe to take during pregnancy and alternatives such as acetaminophen can be used for pain management.
Acetaminophen (Tylenol) is not an NSAID, as it does not have anti-inflammatory effects, but is commonly used for aches and pains, arthritis pain or headaches. It is to be used with caution as it has harmful effects on the liver and patient should be advised to not consume alcohol when taking acetaminophen as it can increase the chance of liver damage. As mentioned above, acetaminophen can be used if necessary for pain relief during pregnancy.
1. Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872–882. doi:10.1001/jama.2018.0899
2. Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic therapy for acute pain. AAFP Am Fam Physician. 2013 Jun 1;87(11):766-72. https://www.aafp.org/afp/2013/0601/p766.html#afp20130601p766-b20
3. Massey T, Derry S, Moore RA, McQuay HJ. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev. 2010;(6):CD007402.