If you are like most Americans the chances are very good that you have one of the following in your medicine cabinet or in a kitchen drawer: acetaminophen (Tylenol), aspirin, ibuprofen (Advil, Motrin IB) or naproxen (Aleve). Then there are the combos that contain multiple analgesics such as Excedrin (acetaminophen and aspirin plus caffeine). How safe is your pain medicine? Most people are clueless!
Occasional vs. Regular Use of Pain Medicine:
Most people take pain relievers for granted. We get that. Drugs like Tylenol or Aleve are so much a part of our culture that we tend to minimize their side effects.
For decades, doctors were the butt of the joke: “Take two aspirin and call me in the morning.” The message was: “Let me sleep!” If aspirin doesn’t solve the problem, call me back tomorrow and I’ll deal with it then.
I accept that a couple of Tylenol tablets for an occasional headache or a little ibuprofen to calm a sprained ankle are relatively safe. But if you are like a lot of Americans, the chances are good that you rely upon over-the-counter pain medicine to soothe your sore joints and relieve muscle aches. When you start using analgesics regularly, there is a price to be paid!
How Many People Take Pain Medicine?
The numbers are astounding! Tens of millions of people take NSAIDs (nonsteroidal anti-inflammatory drugs) on a regular basis. An article published in Arthritis Research & Therapy (July 24, 2013) reports:
“More than 30 million people use NSAIDs every day, and they account for 60% of the US over-the-counter analgesic market.”
That was a decade ago. I suspect the number is higher today.
What about acetaminophen (APAP)? According to the Consumer Healthcare Products Association:
“Acetaminophen is the most common drug ingredient in the United States. It’s found in more than 600 different medicines, including prescription and over-the-counter (OTC) pain relievers, fever reducers, and sleep aids as well as cough, cold, and allergy medicines. Each week, approximately 23 percent of U.S. adults — or 52 million consumers — use an acetaminophen-containing medicine.”
Should We “Trust” Our Pain Medicine?
The manufacturer of brand name Tylenol promotes the word “trust.” It was part of the slogan:
“Trust TYLENOL. Hospitals do.”
You can watch a commercial from 1981 at this link. The reassuring woman tells us that:
“Tylenol is the pain reliever that hospitals use most. That means I can really trust Tylenol.”
The Dark Side of Pain Medicine:
Digestive Tract Distress:
Stomach upset and bleeding ulcers are well recognized complications of nonsteroidal anti-inflammatory drugs. Most individuals are sort of aware of this potential problem. That’s because a fair number of people develop heartburn or gastritis after taking drugs like aspirin, ibuprofen or naproxen.
How common is gastrointestinal (GI) irritation/inflammation? Really common! Here is one estimate (Arthritis Research & Therapy, July 24, 2013):
“About 30 to 50% of NSAID users have endoscopic lesions (such as subepithelial hemorrhages, erosions, and ulcerations), mainly located in gastric antrum, and often without clinical manifestations. Generally, these lesions have no clinical significance and tend to reduce or even disappear with chronic use, probably because the mucosa is adapted to aggression. On the contrary, up 40% of NSAIDs users have upper GI symptoms, the most frequent being gastroesophageal reflux (regurgitation and/or heartburn) and dyspeptic symptoms (including belching, epigastric discomfort, bloating, early satiety and postprandial nausea).”
The authors go on to note that GI symptoms are not predictors of GI damage.
“Approximately 50% of patients with symptoms have no mucosal lesions; however, >50% of users with serious peptic ulcer complications had no previous warning symptoms.”
Do you appreciate the significance of that statement? A lot of people have indigestion but no damage to their stomach lining. Uncomfortable, but not necessarily something to worry about.
Far more worrisome, though, is the opposite problem. More than 50% of patients taking NSAIDs have no symptoms, but “serious peptic ulcer complications.” That is, they could have significant damage to the lining of the stomach but do not realize it. A dear friend (who happens to be a doctor himself) developed bleeding ulcers from aspirin and did not realize how dire his situation was until he started hemorrhaging.
Other Complications of NSAID Pain Medicine:
Many of the other adverse reactions associated with NSAID pain medicine are not as obvious as digestive distress. It can take months or years for people to realize that the medication that they take daily to ease their arthritis pain has caused serious harm.
Kidney damage, high blood pressure and atrial fibrillation are not uncommon complications of NSAIDs. Serious cardiovascular consequences include congestive heart failure, heart attacks and strokes. You can learn more about how arthritis pain relievers can trigger heart and other vascular problems at this link.
If someone over the age of 60 dies of a heart attack while taking ibuprofen or naproxen, most people assume it was because of high cholesterol or just bad luck. Proving that an NSAID was responsible is virtually impossible. But it is not implausible.
Acetaminophen Pain Medicine Is Not Innocent:
Acetaminophen is often perceived as a much safer alternative to NSAIDs. That’s because it is less likely to damage the lining of the digestive tract.
Remember, more than 50 million Americans use a product containing acetaminophen at least once a week. That is almost one quarter of all US adults.
APAP is not as safe as many people think, though. An editorial in JAMA (March 7, 2023) points out that this medicine can cause kidney or liver damage. Each year, Americans make 59,000 emergency room visits for acetaminophen toxicity and there are 38,000 hospitalizations. What’s more, it is the leading cause of liver failure both in the US and in other developed countries.
Limiting the Dose of Acetaminophen?
Some experts have recommended that APAP pills be limited to 325 mg instead of the range of doses currently available. Drug companies love the words “extra strength” but putting 500 mg of acetaminophen into such tablets may make it easier for people to exceed a safe dose.
The FDA has established the maximum daily dose at 4,000 mg. That could be too high for some people (JAMA, July 5, 2006). Because APAP is found in so many different OTC products, from cold and cough remedies to nighttime sleep aids, people can unwittingly overdose. That may be in part because fewer than half of Americans read nonprescription drug labels (American Journal of Preventive Medicine, June, 2011).
Even if people do take the time to read the directions and warnings on OTC drug labels, they might not be protected. Some individuals are especially sensitive to liver toxicity from acetaminophen.
Preventing APAP Pain Medicine Toxicity:
That’s why one solution would be to put the antidote to acetaminophen poisoning right in the same pill. NAC (N-acetylcysteine) can protect the liver from damage if given early enough (Journal of Medical Toxicology, March, 2011). We have never understood why drug companies and the FDA have not seriously entertained this idea.
Other suggestions include limiting the number of APAP pills dispensed in a single bottle or box. That might also be relevant to NSAID safety as well.
Final Words About Pain Medicine:
We need more effective pain relievers that do not cause so much harm. Pain patients have relied on drugs such as aspirin, ibuprofen, naproxen and acetaminophen for much too long. It has been a very long time since the pharmaceutical industry has developed really effective pain medications that do not cause serious complications. Now that I think of it, Pharma has never developed highly effective and safe pain medicine.
Most people, when asked, will tell you that NSAIDs do not eliminate arthritis pain. They can make it more bearable, but they aren’t magic bullets. And by now you realize that the trade offs in terms of side effects are not trivial.
Surely pharmaceutical researchers should be able to develop newer and safer compounds. In the meantime, you may find our eGuide to Alternatives for Arthritis worth reading. It offers a lot of non-drug options for helping control inflammation and pain. This online resource can be found under the Health eGuides tab at this link.
Reader Feedback Please:
Share your own experience with acetaminophen, aspirin, ibuprofen and naproxen in the comment section below. If you have taken prescriptions NSAIDs such as celecoxib (Celebrex), diclofenac (Voltaren), indomethacin (Indocin), ketorolac (Toradol), meloxicam (Mobic), piroxicam (Feldene) or sulindac (Clinoril) please let us know how that went. We would be grateful if you shared this article with friends and family.