With the opioid painkiller abuse crisis raging, many people have a fresh interest in understanding NSAIDs and other painkiller options. What are the differences between painkillers? Which have more, or less, risk?
One major class of painkillers are the non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are a group of drugs used to relieve pain, reduce inflammation, and reduce fever. NSAIDs work by blocking the body from making prostaglandins. Prostaglandins are chemicals that provoke the immune system to create an inflammatory response. This shows up in the body as fever, redness, swelling, or pain. By blocking the body from making these chemicals, NSAIDs can reduce pain, swelling, and fever.
Some NSAIDs are approved for over-the-counter sale at a low strength, and by prescription at a high strength. Other NSAIDs are only available by prescription at a high strength.
There are a lot of myths circulating about NSAID painkillers, so let’s dive in and do some fact checking!
Myth 1: All over-the-counter pain relievers are NSAIDs, and they are all the same
You have aching and swelling in your elbow, and your doctor has told you to take an over-the-counter NSAID to reduce the pain and inflammation. There are several pain relievers available at the pharmacy – are they all basically the same thing?
The answer is no. Always check with your doctor to ensure which over-the-counter pain reliever is recommended for your specific situation.
There are four over-the-counter pain relievers available, three of which are NSAIDS and one of which is not.
- Ibuprofen: Over-the-counter ibuprofen is used to reduce fever and to relieve minor aches and pain. Ibuprofen is taken every 4 to 6 hours. Some common brand names for ibuprofen are Advil, Brufen, Motrin, Midol, and Nurofen. Many combination products for cold symptoms, allergies, migraines, or insomnia also contain ibuprofen, such as Advil Allergy Sinus, Advil Allergy and Congestion Relief, Advil PM, Motrin IB Sinus, and Motrin PM, among others.
- Naproxen: Another over-the-counter NSAID option is naproxen, which is also used to reduce fever and relieve minor aches and pain. Naproxen is taken every 8 to 12 hours. Some common brand names include Aflaxen, Aleve, Anaprox, and Naprosyn0. A combination product for insomnia is Aleve PM.
- Aspirin: Aspirin-like chemicals are found in the leaves from the willow tree, so in this form, aspirin has been used to reduce fever and relieve pain for least 2,400 years! Modern over-the-counter aspirin, or acetylsalicylic acid, is an NSAID that can reduce fever, relieve minor aches and pain, and cause blood to clot less effectively. It is for this last reason that some heart disease patients take a daily, low-dose aspirin to prevent future heart attack and stroke. Aspirin is usually taken every 4 to 6 hours. Common brand names include Bayer and Ecotrin. There are also many combination products for headache, upset stomach, or body aches that contain aspirin, such as Excedrin, Alka-Seltzer, and Pepto-Bismol.
- Acetaminophen: Used for mild-to-moderate pain and as a fever reducer, acetaminophen is NOT an NSAID. Acetaminophen has little to no effect upon inflammation and swelling. Some common brand names for acetaminophen are Tylenol, Panadol, and Anacin. Many combination medications for cold symptoms, allergies, migraines, insomnia, or menstrual cramps also contain acetaminophen, such as Dristan Cold Multisystem, Excedrin, Midol Complete, NyQuil, Robitussin Multisymptom, and Tylenol PM, among others.
Myth 2: There is no risk in taking NSAIDS, especially over-the-counter NSAIDS
Any drug has some risk, and NSAID drugs are no exception, even over-the-counter NSAIDs. Some common side effects of using NSAIDs that may go away on their own are stomach pain, constipation, diarrhea, excess gas, heartburn, or nausea/vomiting.
Serious side effects can also occur, although they are rare. These are heart attack, stroke, high blood pressure, kidney problems including kidney failure, and bleeding and ulcers in the stomach and intestines. The risk of serious side effects is increased for people who take NSAIDs for a long time, at a high dose, or both. The risk of side effects is also increased for people who smoke or drink alcohol while taking NSAIDs.
Why do NSAIDs carry a risk? Let’s look a little deeper into how NSAIDs do their job. NSAIDs work by blocking the body from making prostaglandins, which are the chemicals that cause inflammation and pain. NSAIDs accomplish this by preventing a certain enzyme from working normally. The enzyme is called cyclooxygenase, or COX. There are two forms: COX-1 and COX-2. Both forms of COX normally prompt body cells to make prostaglandins in response to an injury or infection.
Most approved NSAIDs block the actions of both COX-1 and COX-2. One approved NSAID (celecoxib) blocks only COX-2. When COX-1 and COX-2 are blocked, the formation of prostaglandins is blocked as well. Inflammation, pain, swelling, and fever are reduced.
The problem is that COX-1 and COX-2 do other things in the body. COX-1 acts in the stomach to protect the lining from digestive acid, and is needed for the kidneys to function correctly. COX-2 helps keep blood vessels healthy and clear. Blocking COX-1 and COX-2 carries a risk of stomach, intestine, kidney, heart, and blood vessel problems.
There is no need to fear using NSAIDs any more than any other drug your doctor recommends. Remember that all drugs have some side effects. The most important thing is to take NSAIDs exactly as your doctor has prescribed them to reduce the risk of side effects. If using over-the-counter NSAIDs, use them at the dose directed on the package, and limit use to no more than 10 days at a time. If your pain, swelling, or fever lasts more than several days, check in with your doctor.
Myth 3: You can get addicted to NSAIDs if you take them for a long time
Luckily, NSAIDs are not habit forming, and people do not get addicted to them. Because they do not work in the brain, they do not create withdrawal symptoms or cravings when they are stopped.
This is very different from what happens with opioid painkillers. Opioid painkillers can cause dependence (the need to keep taking the drug to avoid a withdrawal syndrome) and addiction (intense drug craving and compulsive use) is because they relieve pain by acting directly in the brain. Although the body signals to the brain that there is pain, the brain does not receive that signal.
Unfortunately, people who take opioids for many days at a time, or a high doses, or both, can become dependent and addicted to them. Opioids actually alter the brain. After a while, the brain only functions normally when the drugs are present. If the drugs are then taken away, withdrawal symptoms, cravings, and compulsive use can be the result. Opioid painkillers must be taken very carefully, and exactly as the doctor prescribes.
It’s very important to know, however, that sometimes NSAIDs are combined with opioid painkillers in a single prescription drug. For example, the drug vicoprofen is ibuprofen combined with the opioid hydrocodone. Combunox is ibuprofen combined with the opioid oxycodone. While the NSAID part of the combination is not habit forming, the opioid part can be!
The bottom line: NSAIDs are very useful drugs that can reduce pain, fever, and inflammation. While no drug is totally safe, the risk of serious side effects with NSAIDs is very low if they are used as prescribed, at the lowest dose possible, and for the shortest time possible. NSAIDs are not habit forming or addictive, although sometimes they are sometimes put together with an opioid in one medication. The opioid part of the medication can be addictive. When in doubt about what type of painkiller is in your medication, always ask your doctor or pharmacist.
Cleveland Clinic. Non-steroidal anti-inflammatory medicines (NSAIDs).
Harvard Health Publications from Harvard Medical School. Acetaminophen safety: Be cautious but not afraid.
United States Department of Health and Human Services. Opioids: the prescription drug & heroin overdose epidemic.
United States Food and Drug Administration. Medication guide for non-steroidal anti-inflammatory drugs (NSAIDs).
United States Food and Drug Administration. The benefits and risks of pain relievers: Q & A on NSAIDs with Sharon Hertz, M.D. September 28, 2016.
United States National Library of Medicine. Medline Plus. Aspirin.
Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Science & Practice Perspectives. 2002;1(1):13-20.
Ricciotti E, FitzGerald GA. Prostaglandins and inflammation. Arteriosclerosis, thrombosis, and vascular biology. 2011;31(5):986-1000.