Making the Most of Over-the-Counter (OTC) Medications
Generally speaking, each of our kits include pain medications/anti-inflammatories. Our larger kits also contain aspirin. Here’s why.
NSAIDs like ibuprofen are great for musculoskeletal pain like sprains, as well as headaches and fevers. Acetaminophen is also excellent in these situations but works differently within the body. Because of their different mechanisms of action, these medications can be taken together or in an alternating fashion (for example, ibuprofen followed by acetaminophen 4-6 hours later, etc). By contrast, the salicylate aspirin, also an NSAID with pain and fever reducing properties, it’s best reserved for its antiplatelet (or “blood thinning”) effects.
Multiple studies have shown that combination acetaminophen-ibuprofen regimens are more effective at controlling acute pain than opioids like oxycodone, hydrocodone, etc.1,2,3
No one should take multiple NSAIDS together, or exceed recommended dosages of any OTC medication in 24 hours, which are usually clearly written on packaging.
The Deeper Dive
This topic is near and dear to my heart, primarily because the medical and pharmaceutical industries have done a poor job at educating patients and caregivers on how these drugs are best used and what their side effects can be. In fact, some of our over the counter medications are actually the most potent (and, in overdose, most dangerous!) medications on the market. Many people feel that acetaminophen and ibuprofen aren’t effective for acute pain, but oftentimes these as well as other OTC medications are underdosed or used in suboptimal settings.
What medications are we talking about?
Non-steroidal anti-inflammatory drugs. These have analgesic (pain relieving), antipyretic (fever-reducing), and anti-inflammatory effects. NSAIDs include medications like ibuprofen (Brand name: Advil, Motrin), naproxen (Brand name: Aleve, Naprosyn), and aspirin which is discussed separately below. Some of these medications have different mechanisms of action – meaning they act on different physiologic pathways and have different side effect profiles.
NSAIDS are generally absorbed in the gut and metabolized by the kidneys, which is also where they are damaging when taken in overdose. The number one side effect of NSAIDS are gastrointestinal problems, from reflux and the development of ulcers to gastrointestinal bleeding. This is much less likely at low, OTC dosages and when taken for a short period of time (a few days). But, this is why they are not recommended in people who have a history of peptic ulcer disease or gastrointestinal bleeding, or who take blood thinner medications. Ibuprofen also has an important effect on platelets, which help blood to clot, making platelets less effective over a 24 hour period4. Also important to note, NSAIDs should not be used during pregnancy.
Aspirin (acetasalicylic acid, a salicylate)
While also an NSAID, antipyretic, and analgesic, aspirin is best known for and most widely used in the medical community for its platelet inhibition effects, which are longer lasting than ibuprofen (for the life of the platelet, or about 10 days5). This is the drug that has the greatest benefit on mortality in ongoing myocardial infarction (a heart attack in the sense that the coronary arteries that supply blood to the heart are obstructed, versus a cardiac arrest, which refers to the heart stopping and may be due to many underlying medical issues).
Brand name Tylenol. This is not an NSAID, but is a highly effective analgesic and antipyretic. This is metabolized by the liver, which is where it exerts the most damage if taken in overdose. A common misconception is that you can’t take acetaminophen with alcohol and this stems from both of these substances being harmful to the liver in great quantities. The maximum dosage of acetaminophen for someone with a healthy liver is 4g or 4000mg in 24 hours (FYI this is a hidden ingredient in many OTC cold formulations, and these should be included in the 24 hour total). Acetaminophen is generally gentle on the stomach.
The Bottom Line
Multimodal pain control can offer the benefit of taking each medication at lower doses, which translates to fewer side effects and better therapeutics. Ibuprofen and acetaminophen have been shown to be highly effective at controlling acute pain – even in the postoperative setting – so effective that they can reduce or eliminate the need for opioid pain medications. They can be used together because they act in different ways. Ibuprofen dosages as low as 200-400mg per dose have been shown to be effective in combination with acetaminophen. Aspirin is a special NSAID medication that we put in CFA kits for its mortality benefit in instances of suspected myocardial infarction (i.e. fewer people die if treated with this when having a heart attack due to impaired blood flow to their coronary arteries).
We recommend that people talk with their physician about starting medications and appropriate dosages for their individualized medical care. This is a platform for education, and should not be substituted for medical advice.
Cramer JD, Barnett ML, Anne S, Bateman BT, Rosenfeld RM, Tunkel DE, Brenner MJ. Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Otolaryngol Head Neck Surg. 2021 Apr;164(4):712-719. doi: 10.1177/0194599820947013. Epub 2020 Aug 18. PMID: 32806991.
Pergolizzi JV, Magnusson P, LeQuang JA, Breve F, Taylor R, Wollmuth C, Varrassi G. Can NSAIDs and Acetaminophen Effectively Replace Opioid Treatment Options for Acute Pain? Expert Opin Pharmacother. 2021 Jun;22(9):1119-1126. doi: 10.1080/14656566.2021.1901885. Epub 2021 Jun 14. PMID: 33689517.
Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: translating clinical research to dental practice. J Am Dent Assoc. 2013 Aug;144(8):898-908. doi: 10.14219/jada.archive.2013.0207. PMID: 23904576.
Rainsford KD. Ibuprofen: pharmacology, efficacy and safety. Inflammopharmacology. 2009 Dec;17(6):275-342. doi: 10.1007/s10787-009-0016-x. Epub 2009 Nov 21. PMID: 19949916.
Fuster V, Dyken ML, Vokonas PS, Hennekens C. Aspirin as a therapeutic agent in cardiovascular disease. Special Writing Group. Circulation. 1993 Feb;87(2):659-75. doi: 10.1161/01.cir.87.2.659. PMID: 8425313.