Differences Between Common Pain Relievers

Over-the-counter (OTC) pain relievers are used to reduce or relieve many types of pain including headaches, arthritis, sprains and strains, back pain, earaches, toothaches or pain from a cold, flu or sore throat.  Some of these products are taken internally (by mouth), while other are applied topically. 

Oral Medications:

Oral OTC pain medications can be effective at relieving many types of mild to moderate pain. Some will also help to decrease inflammation.

There are two main types of oral OTC pain medicines:

• Acetaminophen (Tylenol®) seems to work by blocking pain signals and increasing the body’s overall pain threshold.   It also helps to control body temperature. It is typically recommended for temporary relief of fever and/or minor aches and pains due to cold, headache, backache, toothache, and premenstrual/menstrual cramps. It can also help relieve the pain from muscle aches and osteoarthritis, but it does not help with the inflammation associated with these conditions.

o  When taken as directed, acetaminophen has low risk of side effects. However, higher doses (more than 4,000mg/day) are associated with an increased risk of liver damage. This risk is higher for people who have existing liver disease or long-term alcohol use.

o  While using this product, you should not consume 3 or more alcoholic drinks each day.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease the level of prostaglandins, hormone-like substances the body produces, that promote pain and inflammation at nerve endings. Reduction of prostaglandin levels decreases the feeling of pain and inflammation. NSAIDs such as aspirin, naproxen (Aleve®), and ibuprofen (Motrin®, Advil®) are indicated for the temporary relief of minor aches and pains due to arthritis, muscle aches, backache, menstrual cramps, headache, toothache, the common cold and also to temporarily reduce fever. 

o  NSAIDs may cause severe stomach bleeding. The chance is higher if you:

- are age 60 or older

- have had stomach ulcers or bleeding problems

- take a blood thinning or steroid drug

- take other drugs containing NSAIDs

- have 3 or more alcoholic drinks every day while using this product

- take more or longer than directed

o  NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke. These can be fatal. The risk is higher if you use more than directed or for longer than directed.

o  People who have problems or serious side effects from taking an NSAID; have high blood pressure, heart disease, liver cirrhosis, kidney disease, asthma, or had a stroke; or are taking blood thinners should check with their physician before using.

o  Aspirin should not be used by children and teenagers who have or are recovering from chicken pox or flu-like symptoms. When using aspirin, if changes in behavior with nausea and vomiting occur, consult a physician because these symptoms could be an early sign of a rare but serious illness called Reye’s syndrome.

Some products contain a combination of products such as acetaminophen, aspirin and caffeine (i.e. Excedrin® Extra Strength, Excedrin® Migraine) which are used for headaches while others combine acetaminophen and ibuprofen (Advil® Dual Action) for pain relief.  In addition, many OTC cold and flu products also contain acetaminophen or an NSAID to help with pain and fever. Make sure to check the ingredients of the products you are taking so you don’t “double-up” on an ingredient. Ask your doctor or pharmacist if you are unsure.

Topical Medications:

Those who are reluctant to take pills may choose a topical pain reliever. These medications are applied to the area of the skin where the pain is felt such as a painful joint or strained muscle. They are available in creams, gels, sprays and patches and are usually best used on joints that are close to the skin’s surface like the hands and knees, since that’s where they are absorbed.

Some active ingredients, found either alone or in combination, in OTC topical pain medications include the following:

• NSAIDS [diclofenac (Voltaren Arthritis Pain Gel), trolamine salicylate (Aspercreme®), methyl salicylate] penetrate the skin, enter tissues or joints, and help to decrease inflammation to produce a local analgesic effect. Topical NSAIDs can provide pain relief from acute musculoskeletal injuries like sprains and strains, and osteoarthritis of the knees and hands. 

o  These products have a lower risk of stomach irritation than their oral counterparts and may be a good alternative for older people or individuals who can't tolerate oral NSAIDs.

o  People who are allergic to aspirin or are taking blood thinners should check with their physician before using these products.

• Capsaicin (Capzasin™, Zostrix®), an ingredient derived from chili peppers, causes a burning sensation. These creams deplete the nerve cells of a chemical called substance P that is a pain messenger in the body.

o  Application can cause the skin to burn or sting, but this discomfort typically decreases within a few weeks of daily use.

o  Wash hands thoroughly after each application and avoid touching eyes and mucous membranes. You may need to wear latex gloves when applying the cream.

o  Capsaicin is most effective if used several times a day. It might take up to 14 days to achieve the full effect.

• Menthol and Camphor are counterirritants that produce a cooling sensation to help temporarily create a diversion from pain or other irritations. They are used alone or in combination with other ingredients such as methyl salicylate or lidocaine.

• Methyl Salicylate is classified as an NSAID, but also has counterirritant properties. This product increases blood flow to the application site, producing a warm sensation and temporarily overriding the ability to feel pain. It is typically combined with menthol and/or camphor.

• Lidocaine is a topical anesthetic which desensitizes aggravated nerves producing a numbing sensation to decrease pain.

It is important to remember that these products, both oral and topical, can have both risks and benefits. Check the ingredients before using multiple products. Make sure not to use more than 1 OTC pain reliever at a time, unless otherwise directed by your physician.

Always follow the directions on the packaging and check with a physician before adding a new medication to your current therapy.

In most cases, OTC medications can help to relieve acute pain symptoms. Contact your physician if:

• Your pain is getting worse or lasts more than 10 days
• You have redness or swelling in the painful area
• Your pain is constant or intense.
• You develop new symptoms such as tingling, numbness, weakness, burning.
• You have been using OTC medications and/or other home therapies for over 7 days.

In addition to OTC therapies, your physician may suggest prescription medications, alternative remedies and lifestyle changes to help to improve your pain and quality of life.

Sources:

1.  Bayer HealthCare.  Aleve Caplets Package Insert.  http://labeling.bayercare.com/omr/online/aleve-caplets.pdf. Last updated October 2020.

2.  Bayer HealthCare. Aspirin 325mg Package Insert. http://labeling.bayercare.com/omr/online/aspirin-regimen-bayer-regular-strength-325-mg.pdf. Last updated March 27, 2018.

3.  Clinical Resource, Topicals for Pain Relief. Pharmacist’s Letter/Prescriber’s Letter. April 2020.

4. Familydoctor.org. Pain Relievers, Understanding Your OTC Options.  https://familydoctor.org/pain-relievers-understanding-your-otc-options/?adfree=true. Last Updated: July 22, 2019. Accessed January 11, 2021.

5. Harvard Health Publishing. Harvard Medical School. Rubbing it In. https://www.health.harvard.edu/pain/rubbing_it_in. Last updated: May 14, 2019. Accessed January 11, 2021.

6. Johnson & Johnson Consumer Health. Motrin. https://www.motrin.com/products/motrin-ib. Accessed January 11, 2021.

7.  Johnson & Johnson Consumer Health. Tylenol. https://www.tylenol.com/products/tylenol-extra-strength-caplets#warnings. Accessed January 11, 2021.  

8.  Mayo Clinic.  Self-care Approaches to Treating Pain. https://www.mayoclinic.org/self-care-approaches-to-treating-pain/art-20367322. October 31, 2017. Accessed January 11, 2021.

9.  Mayo Clinic. Arthritis Pain Treatments Absorbed Through the Skin. https://www.mayoclinic.org/diseases-conditions/osteoarthritis/in-depth/pain-medications/art-20045899. July 23, 2019. Accessed January 11, 2021.

10.  Pharmacy Times. Yvette C. Terrie. Understanding Topical Analgesics. https://www.pharmacytimes.com/publications/issue/2010/September2010/TopicalAnalgesics-0910. 2010-09-28 12:59:15. Accessed January 11, 2021.

11.  US National Library of Medicine. Pain Relievers. https://medlineplus.gov/painrelievers.html. Last updated December 7, 2020. Accessed January 11, 2021.

12.  Zostrix. Zostrix Product Label Info. http://zostrix.com/. Accessed January 11, 2021.