Choosing an Analgesic: What a Pain!

By Amber Dale Sapp, PharmD, RPh

 Undoubtedly, you’ve been there.  After a day of overdoing it at the gym (what with that New Year’s resolution to become more fit), you stare blankly at the analgesic shelf at your pharmacy, confounded by the seemingly indistinguishable choices for pain relief.  Television and print advertisements further confuse the issue by promising faster, stronger, safer pain relief.  Each product claims to be preferred by doctors, recommended by pharmacists, and tested by moms.  So, what really is the difference in the many over-the-counter anti-inflammatory and pain reliever medications?  You will be relieved at the simple answer: not much.

It may be helpful to get an overview of the classes of pain relievers currently on the market.  First are the salicylates, namely aspirin preparations.  Aspirin is found in many products—Bayer, Bufferin, and Excedrin, to list a few.  Acetaminophen is the second OTC analgesic, and can be found in the Tylenol brand.  Third, and most diverse, are the non-steroidal anti-inflammatory drugs, or NSAIDs.  The only three OTC medications in the NSAID class are ibuprofen, ketoprofen, and naproxen.  Finally, glucosamine products offer an alternative to anti-inflammatory agents for treatment of arthritis-related pain.

Aspirin works by blocking pain-mediating and inflammatory chemicals in the nervous system. Aspirin also blocks platelet aggregation in the blood stream.  (Platelets are one component of blood clots.)  As such, doctors now recommend some patients take an aspirin tablet daily to reduce risk of strokes and heart attacks.  Studies have shown that low-dose aspirin therapy (81 mg per day) is no more effective in most cases in reducing heart attack risk than a full-strength tablet (325 mg).  Aspirin is an acidic chemical, and it can wear away the stomach lining.  Over time, a bleeding ulcer could result.  This effect may be diminished, but not eliminated, by taking an enteric-coated product.  Additionally, because of the risk of Reye’s syndrome, parents should never give any salicylate to a child under eighteen years of age that has a fever.  With regards to analgesia, aspirin’s risks generally outweigh its efficacy.  Clinicians now rarely recommend aspirin for pain relief.

Acetaminophen is a common ingredient in many OTC products.  It works in a similar manner as aspirin, but has no anti-inflammatory properties.  It is a mainstay for reducing fever and treating mild headaches. Acetaminophen can be safely used for pain-relief in patients who are at risk for ulcers, who are prone to bleeding disorders, or who are allergic to salicylates.  That is not to stay that acetaminophen is without risk. An average-sized adult should not exceed 4000mg of the drug per day.  To do so puts the patient at risk for liver failure.  People with liver diseases (hepatitis, cirrhosis), as well as active alcoholism, are even more at risk for acetaminophen overdose.  A typical adult dose for short-term pain relief is 325-500 milligrams every 4-6 hours, without regard to meals.

The third, and most popular class of OTC analgesics are the NSAIDs.  This type of drug works by inhibiting generation of pain impulses at the site of injury.  NSAIDs also work to reduce inflammation.  Sports injuries, osteoarthritis, and muscle aches are all the result of inflammation.  Ibuprofen is the active ingredient of the Motrin and Advil brands.  The only OTC strength available is 200 mg per tablet.  A normal adult dose of ibuprofen is 200-400 milligrams every 4-6 hours (maximum 3200 mg per day).  Naproxen, or Aleve brand, has the benefit of a longer duration of action.  A 220 milligram tablet need only be taken every 8-12 hours (daily maximum of 1100 mg).  Ketoprofen, found in Orudis KT, is a slightly more expensive NSAID, but it offers no therapeutic benefit over others in its class.  Ketoprofen is usually taken as 12.5 milligrams every 4-6 hours (maximum of 300 mg per day).  People respond to this drug class in very diverse ways.  If ibuprofen does not provide full relief of pain, it is likely that another in that class will be effective.  Similar to aspirin, NSAIDs can wear away stomach lining, and should always be taken with food.  Moreover, NSAIDs do interact with many over-the-counter and prescription medications so it is wise to consult your pharmacist before starting self-treatment.

Of late, a lot of press has been given to glucosamine as treatment for the pain associated with osteoarthritis.  Arthritis is a condition wherein the lining of our joints (cartilage) wears away with age, leaving little or no padding for movement. New research suggests that glucosamine supplements might slow the progression of osteoarthritis.  This product is thought to stimulate cartilage growth, rebuilding that protective padding in the joints.  There is more study needed, but it seems to work as well as ibuprofen for arthritis pain.  The recommended dose is 1500 mg per day.  However, this regimen may require 4 to 8 weeks to relieve pain.  An NSAID may by continued for the first month or two when beginning glucosamine therapy.  As an aside, clinicians have noted that some diabetic patients experience more difficult blood sugar control while taking glucosamine.  Ask your doctor or pharmacist if this is something about which you should be concerned.  Finally, many products, like Cosamin and Bioflex, will try to lure you with additives like chondroitin and MSM.  There is absolutely no proof these products work any better than glucosamine alone.

As you make good on that resolution to become healthier, you will no doubt experience aches and pains related to your new regimen.  Before you return to your pharmacy’s analgesic shelf, make another resolution to be more informed about what awaits you there.

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Dr. Amber Dale Sapp is a pharmacist in LaGrange.  She received a doctorate in pharmacy from the University of Kentucky in 2000. Her professional areas of interest include chemical dependency and working with deaf patients using American Sign Language.  She can be reached at


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