The dos and don'ts of taking over-the-counter pain medications

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You're listening to LifeKit from NPR. Hey everybody, it's Mario. For a decade plus, when I would get my period, I would have terrible cramps the first day, and I would just ride it out like I'd be doubled over, unable to leave the house really. I tried heating pads which do help, but for some reason, I didn't think I should take a

pain killer. I don't know, I guess I just thought it was safer to go natural. But then one day when I was maybe 25, I popped an ibuprofen, and then a short time later, the pain was gone. It would start to creep back up again a little later, and then I took another,

and after that I was over the hump. My cramps were manageable at that point.

I kind of regretted waiting that long. I went through so much unnecessary pain. Pain is a part of the human experience. We get cramps and aches and migraines. We burn our hands, cooking, or trip, and spring and ankle, and when you're right in the middle of one of these moments, and feeling that pain deep down in your bones. Pain killers, especially the over-the-counter kind that are easy to get, they feel like a miracle. Now they are not without risks. If you take

over-the-counter pain killers the wrong way, or take too many of them, you can have serious complications, or even die. And they can mask your problems, too. Pain is there for a reason. It's one of the ways our bodies warn us that something is wrong. Dr. Trisha Piss Rica is an instructor at Harvard Medical School. And she says we need to consider that when we're thinking about taking

“pain killers. I think there's a question that we should ask ourselves when we have pain,”

which is that is this like sort of a one-time thing, or once in a blue type of moment that I'm having, or am I going to the doctor all the time for pain? And is it the same kind of pain? Because I think in my mind that really differentiates what we need to be doing about it. Because if this pain keeps coming up, it might be time to see a doctor. Make sure everything's okay. Life kit reporter Andy Tagle has been looking into how we use over-the-counter drugs. And in this

episode, we're going to talk specifically about pain killers like acetaminophen and NSAIDs, non-steroidal anti-inflammatory drugs. I be profan, neproxin, aspirin, and like. These are some of the most commonly used over-the-counter medications. Andy talked to Dr. Piss Rica and to two pharmacists, including Blama Twigby at UCSF's Outpatient Pharmacy at Mission Bay, who says, "Yeah, talk to your pharmacist. This is their world, and they have the training to help you."

And we can help you make a safe choice, and we'll ask you questions that you may not even think about, like what other medications are you taking. Often times there can be drug interactions, with prescription medication and an over-the-counter med. So it's really to your benefit to ask

“a pharmacist about what you should use. Andy and I are going to talk about how to use these drug”

safely, what they're each good at, and what you might consider if you're looking for an alternative. That's coming up after the break. We flush a lot of things down the toilet. You know, the obvious ones, but drugs like cocaine are also going down the drain, and into our waterways. That's changing the animals that live in it. It's definitely present in most of the ecosystems on earth. Now, unfortunately,

we're only really starting to scratch the surface and do other standing potential consequences of that. Forget cocaine bear. Learn about cocaine salmon, on shortwave, in the MPR app, or wherever you get your podcast.

Okay, to start, I've always wondered why are some meds available over the counter,

while others require prescription? Yeah, me too. It's a good question. So if a medicine is available over the counter, that means it's been deemed safe and effective by the FDA for most people if used correctly, and they have to meet three basic criteria in order for that to happen. One,

“you have to be able to self diagnose the problem. Like, I have a headache. From there,”

two, you have to be able to self treat that headache, and then three, there has to be a low potential for misuse and abuse. All of these medications are tested and regulated through something called a drug monograph. And what those are are kind of a recipe book, which cover acceptable ingredients, doses, formulations, and labeling. These are continually updated by the FDA to make sure that the public is safe and informed. But if you use over the counter meds the wrong way, you could die,

right, in some cases. They're not without risk. They can be fatal or addictive. Yeah, I'm Ariel. Just because an over-the-counter med is deemed safe, doesn't mean they can't still be harmful. So Dr. Trisha Pussrecha, she's the physician we heard at the top, and she's also done a lot of

by the label and our medical provider, but that's just not always how it happens."

There was a study in 2018, which I cite often, which is, which on that more than a third of over-the-counter-eye-reproven users, we're taking other insects, like aspirin and approximately the same time. And most of those people didn't realize all the products they were taking, were insects in the first place. So what that means is you can easily enter this false sense of security that everything you get over the counter must be completely safe. And that's really

“not true. They can be safe, and they can be effective. But you need to take the time to understand”

what it is you're treating, be confident that medication you're taking treats that thing, and be clear on the optimal way to take it. For example, Pussrecha mentioned patients of hers who suffer from heartburn. So they would take proton pump inhibitors like Prylasac, and would reach for that medication right before bed. Well, right before you go to bed is not a very helpful time to take it. It would have been much more efficacious if you'd taken it 30 minutes

before your meal. Sometimes that entire instruction just gets lost in translation, and they think that although proton pump inhibitor isn't working. This medication isn't working for me. I have something else going on, or my heartburn is refractory to medication. Actually, that's not the case at all. It's just that we weren't taking the medication optimally, and sometimes having a conversation with your healthcare providers, this is what I've been trying, could help clear that right up.

“Yes, so who can we talk to about over-the-counter drugs, and how to use them, if we're not sure?”

Yeah, good news on that front-marial. You don't have to make an appointment with your doctor. There are other trained professionals out there ready, and willing to help with this exact problem. So just like we heard at the top from UCSF Pharmacist Plumma Twedby, you can walk into any local pharmacy and talk to your pharmacist. When you do that, they'll need to know what chronic diseases you have, what medications you're taking, and a note that should include any vitamins or supplements.

All right, let's get into some of the specifics. One commonly used over-the-counter pain killer is a acetaminophen, also known by the brand named Tylenol, and it's used for fevers and body pain. So yeah, the experts who talk to you would agree, that's the go-to reason,

and they would also recommend reaching for a acetaminophen first, because generally speaking,

it's gentler on the body than NSAIDs and the safer choice overall. With some caveats. Yeah, what are the risks if you're taking acetaminophen? This is the one I know can cause liver damage if you take more than you're supposed to. Yeah, that's exactly right. So it's called acetaminophen toxicity, and according to recent data, it's one of the most common causes of liver transplantation in the U.S. And it is responsible for over 56,000 emergency room visits

over 2,600 hospitalizations in a 500 deaths per year. Now, I know that sounds horrible, but when used appropriately and safely, most people don't have to worry. This is Candice Euronus, she's a professor of clinical pharmacy, also at UCSF, and some of her work entails educating providers and patients about the appropriate use of medicine. Okay, so what is the recommended dosage for acetaminophen? To keep your liver

safe. The maximum dosage is no more than four grams or 4,000 milligrams in 24 hours, and you also want to be really careful of alcohol consumption, because alcohol is also hard on your liver. So doing both increases your risk of severe liver damage. I asked her experts if they could give us any hard and vast rules around drinking and Tylenol, you know, is there a time limit maybe or within a 24-hour period, a certain number of drinks, and they said that's not really how it

works, but post-reaches says the thing about acetaminophen toxicity is it's often an acute presentation, meaning the damage hits hard and fast. It's often because they're drinking heavily. And you feel a little sick after you've had a lot to drink, and then you might start to kind of lose track of how much you're self-medicating at that point. So clearly, that's something you want to avoid. So so Runa says there's no magic number here, but if you have any pre-existing

liver condition, liver disease, best to avoid acetaminophen. And then more generally, if you know you've been drinking and then say you're suddenly hit with a fever or you screen your ankle, that's probably an instance to look for other pain relief options. The more of the story is if you're a regular trigger of alcohol that you might want to avoid using acetaminophen, as your primary

pain reliever, but again, I always would recommend that people talk to their pharmacist or their

“doctor about the details. Any other drug interactions we should know about with acetaminophen?”

Yeah, you know alcohol is a biggie. If you're on blood thinners, like warfarin, that's the only other major one often mentioned. Any other prescription meds you have will likely come with a warning label saying you shouldn't take it with acetaminophen, but of course, talk to your doctor, talk to pharmacist if you have concerns. All right, another commonly used over-the-counter pain killer is the NSAID, which stands for non-steroidal anti-inflammatory drug. I'm assuming

like they do. They reduce pain by limiting your body's production of certain chemicals that

cause inflammation. So you want to reach for these if you're dealing with any type of swelling, bruising, muscle aches and pains, you know, a headache, a spring angle, muscle soreness, after a big workout, acetaminophen, on the other hand, works differently. It's a bit of a black box, but we know it works on different pain receptors and helps reduce and regulate body temperature.

“That's why your doctor pharmacist will often steer you in one clear direction for fever,”

but for pain, it's not so clear cut. Depending on the kind of pain and it can sometimes be hard to know when you're just like, "Why have a headache?" or, you know, "My back hurts. It's hard to know sometimes exactly what's driving it. Maybe muscle skeletal injury, it may not be."

Pain often has an inflammatory component to it, in which case people often find that NSAIDs are just

much more efficacious for pain than the acetaminophen. And then it's also confusing when you're walking through the medicine aisle, right? Because with acetaminophen, there's just the one drug, but there are lots of different types of NSAIDs. So how do you know which one to choose? Is there one that's stronger than the others or more effective for certain kinds of pain? Yeah, so let's compare just two of the most popular well-known NSAIDs. I'd be pro-fin,

brand names like Adville or Motron and Naproxin, brand name Aleve. Naproxin or Aleve is longer lasting. So you only have to take it every eight to 12 hours, and there's a maximum daily dose of 660 milligrams. So if you're someone who doesn't like taking pills, that might be

“appealing. But some people find that Naproxin makes them drowsy, so you have to make sure that's”

a side effect that you can plan for. I'm a pro-fin on the other hand, doesn't last as long. You take

them every four to six hours as needed, and you can take up to 1200 milligrams a day. So if you're looking for more regular, quicker hits of relief throughout the day, maybe you're dealing with newer pain, like from a break or fall, this type of NSAID might make more sense for you. Okay. Also, it seems safe over the counter for the 12 younger crowd while Naproxin isn't. So any parents can take note there. Bottom line, best is relative, and importantly, each medication

comes with risk and potential side effects. Okay, and what are the risks of taking NSAIDs? Yeah, so you know, a lot of people would choose NSAIDs over a seed of benefit because they find them more effective. The thing about that is they can also be riskier. So with a lot of NSAIDs, there are potential effects on the kidneys and the GI tract, which is why it's important not to take these meds on an empty stomach. You want to give yourself some buffer. Taking NSAIDs could

lead to minor uncomfortable side effects, like gas, heartburn, nausea, diarrhea, up to more serious complications. Specifically, they could have an impact on the blood flow in the stomach and the small intestines that might lead to gastrointestinal ulcers or bleeding. So, Pocerecia says, if you feel setting sharp stabbing pains in your gut or if your stool is black after taking these meds, those are emergency room situations because they could be signaling some of those more serious

gastrointestinal problems. And her big problem with NSAIDs is that she says sometimes even if you're following the recommended dosage and usage, you can still experience negative side effects if you take them over a longer period of time. There are many formulas, but you can stick to the exact instructions. But if you do that every single day and you do chronically, even sort of going by the book, you have put yourself at higher risk of damage. And that's just because of the

nature of the medication. Okay, and are there any drug interactions we should know about when it comes to NSAIDs? Yeah, there are a few more than a seed of benefit. So, if you're somebody who's taking a regular blood thinner, if you have atrial fibrillation or if you're on heart medications, also quarter of the steroids, those are all conditions in which experts say to reach for a seed of benefit in said events. We'll have more life kit after the break.

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Is that okay? Short answer, this is okay for both kids and adults. Both twigby the pharmacist from UCSF and Dr. Pussricha signed off on alternating between a seed of benefit and NSAIDs,

“with the caveat that you should always take the smallest amount that you need for the shortest”

interval possible to get the job done. And if you're not feeling better after a few days, Pussricha says certainly within three or four, talk to your doctor. Now, if you're in a lot of pain or you're treating a flu with a high fever, what should your schedule look like? Pussricha says, "You still want to follow the guidelines on the back of the NSAID box, but if needed, it's okay to supplement with a seed of benefit about halfway through." So, let's say you take some

your next dose, but at 3pm your fever spikes. It's okay to take a dose of pain at all.

“And is the idea here that you just want to limit your use of NSAIDs as much as possible?”

Yeah, that's definitely part of it. But there's also been some recent research that alternating between a seed of benefit and ibuprofen is a really effective pain relief method, especially for acute pain. I'm also wondering about combination pain relief meds, like, etc, or might all PM. Where do they fit in with this conversation? Is there anything people should keep in mind before reaching for one of these? Mario, I'm so glad you brought that up. I get migraines fairly often,

and if I don't take etc in time, I am completely out of commission. So, this was a big question for me.

I asked Pussricha about this and she had a couple of tips. The first, very similar to what she said

at the very top of the episode, know what's in your medications and be very careful that you're not accidentally overmedicating yourself. And also, think about your specific health needs. Are you somebody who, you know, you take a daily aspirin every day anyway because of your heart health? Think about that when you're grabbing an etc and you have a headache. Are you already on a blood thinner? And now you're grabbing one or two more NSAIDs. You're putting yourself at a much higher

risk than somebody who doesn't take a blood thinner every day anyway. So, they're fine. They're good medications that get the job done, but just try to be very, very careful that you know what is in the ingredients of everything that you're putting into your body. And the other tip she had here about NSAIDs was to be aware of your timing. Sometimes people want to hold out on a headache or menstrual cramps. They want to, you know, write it out. Go with a stoic route. But she says,

sometimes it makes more sense to take a small dose when you start to feel the pain. As opposed to now, you know, you've let two or three hours go by. Got this raging headache. Then the medicine doesn't go a lot more ketchup work to do. And then then then I find that

that's when people, they take that first dose. So, it doesn't work. So, then, you know,

half an earlier, let me just try one more dose. That doesn't work to it. They keep, and then suddenly you end up taking more medicine. And if you had just taken it at the start of the problem because it's just much easier to, you know, turn off the faucet than it is to plug a leak later and that sort of the situation people end up in. Yeah, that also sounds like it could be dangerous. You're absolutely right. You know, Mary, out when you're in a lot of pain,

it can be really tempting to just throw whatever you've got at it. Maybe just pop a few extra Advil. But Pizzree just says, that's a really bad idea because depending on how you do it and what you're trying to treat, doubling down like that, not only increases your risk of experiencing side effects, but it also won't necessarily provide you any more pain relief. That's because NSA's have a ceiling effect. After which, you know, you've taken a certain amount of that medication,

and you're not actually getting any more bang for your buck. So, she says she's seen patients come into the emergency room leading from an ulcer because they took too much pain medication. And probably, whatever was causing the problem in the first place, you know, wasn't going to respond fully to, you know, NSA's in general. Like, they, they probably hit that effect. But then they just kept going. It's all they were getting then. We're the side effects of the medication. And they were

like, stopped receiving any benefit from it. So, you know, the takeaway here, as we've said, I feel about a million times at this point, talked to your pharmacist, talked to your doctor, early, and often. Make sure the pain you're feeling can and should be treated with an OTC medication,

and bonus tip from Pizzreecha here. If it does, you can always buy generic versus branding pills,

because she says they will always have the same active ingredient. They have to and they've gone through the same FDA approvals. So, why not save yourself a few bucks? I guess it's worth saying here,

“as we talk about pain killers, over the counter medication isn't the only option, right?”

There are things you can do that don't involve taking a pill. Yeah, Mariel. You know, the thing about over the counter medication is because it's so readily available, because it's so easy to reach for. Often, patients just don't even consider talking about what other options might be available for their back pain, their period cramps, their migraines, you know. But we have other ways that we can treat ourselves first when we're in pain. If it's a migraine, maybe it's hot packs or cold packs,

maybe a little yoga, and another option you might try depending on what it is you're treating, topical pain medication. There are many ends of the available over the counter in cream, gel, or patch form. So, you can pick up, I would profan as a cream, for example, Cerunus mentioned at Clothenac, popular for arthritis pain, and Pizzreecha mentioned kept season, which, fun fact, uses the spicy elements of chili peppers to help relieve pain. It's kind of like a

fight fire with fire approach. And well, some of these may cause some skin irritation to some people. Overall, Pizzreecha is a big fan of avoiding oral endsides where you can, and says topical

“endsides can be really effective for pain relief. I think sometimes people just don't think to try it,”

and because it's like way less common, but it's all there, sitting in the drug store for you. All right, here's a question that I think comes up a lot for folks who have over the counter meds in their cabinet. When do I have to throw them away? Because like, sometimes I'll realize

I am very guilty of this. I have done it a lot. Tugby says, don't do it. Stop doing it.

“Back to the ingredients starts to degrade, once the expiration date hits, and particularly with”

their expired prescription medications, you can now drop that stuff off at your local pharmacy, and they'll dispose of it for you without, you know, throwing it into a toilet and damaging, you know, the water system, but in terms of over-the-counter medications that are expired, do not use them. They're not going to help you. So what Tugby says here is, if this is something

you've done before, you likely haven't harmed yourself if you've taken a paying killer that was a

few months old, just might not have been as effective as you'd want it to be. But it's still just

“not a good practice, not something you want to make a habit of. So check those meds and cabinets regularly,”

do a sweep, anything that's expired, take a cheerlego pharmacy. Before we're reporting this episode material, I'll be honest, I would just toss old pills in the trash. Yeah, I need to, but you don't want to do that for a couple of reasons. If you have any pets or small kids at home,

that's a big safety risk. You wouldn't want any little accidentally ingesting those inspired meds

if they somehow get into your garbage. And it can also be bad for the environment if those medications end up in your local landfill. So just bring them to your nearest drug take-back location or you can mail them using prepaid drug mail-back envelopes. All right, Andy, thank you for looking into this. Thanks, Marylle. All right, it's time for a recap. Over the counter pain medications can be really helpful and effective, but remember they're not without risk. So aim to take the smallest amount you

need for the shortest time possible to treat your pain. In general, a seat of minifin works well

“for favors, but you should see your clear of it if you've been drinking alcohol. An N-sets work”

better for pain plus inflammation. Think about a spring dangle, for instance, but they can be hard on the stomach. So it's best to take them with food and be aware of any possible side effects. Think about your lifestyle, chronic conditions and other medications before you reach for an over-the-counter medication like do you have a heart condition, liver condition, are you on a blood thinner, understand any potential complications before you decide and don't stray from the

directions on the box or a bottle. Pharmacists are a great resource when you have questions about over-the-counter drugs and if you find yourself continually reaching for an over-the-counter pain reliever, talk to your doctor. By the way, just a reminder, you can sign up for life kit plus to support our work at NPR and get curated playlists on popular life kit topics. Start listening today at plus.npr.org/lifekit. This episode of Like It Was Produced by Claire

Marie Schneider, our digital editor is Malica Greb, our visuals editor is CJ Rikalan. Megan Kane has our senior supervising editor and Beth Donovan is our executive producer. Our production team also includes Margaret Serrino and Sylvee Douglas. Engineering Support comes from Quacili. I'm Marie Alcegadra. Thanks for listening. Communities across the country are adapting to a warming planet, hear their stories and lessons

of local climate action, join us for climate solutions week from NPR. Visit NPR or.org/climateweek.