The medical establishment finally got the message on opioids after tens to thousands of deaths from overdoses and billions in lawsuits. Doctors are now offering prescription-level painkillers such as acetaminophen (Tylenol), and nonsteroidal anti-inflammatory drug (NSAIDs), to patients for acute pain. Instead of prescribing OxyContin and Percocet, they are offering them prescription-level dosages of the most popular over-the-counter painkillers like acetaminophen or Motrin (or Advil). Research has shown that five hundred mg (mg), of acetaminophen combined with 200 mg of Ibuprofen for dental pain and post-operative pain is more effective than opioids. The combination also causes fewer side effects and virtually no risk of addiction. Even for minor fractures and severe kidney stones, NSAIDs can be used. They are also safer than, and at least as efficient as opioids for pain in the joints and lower backaches.
There is no safe drug. This holds true for the most trusted painkillers. Beyond the obvious dangers, NSAIDs can cause severe bleeding and irritation to the gastrointestinal tract. In fact, acetaminophen can be poisonous in excess of 4,000mg daily. These problems are just a few of the many that have been documented over the years. It is sensible to examine the potential dangers of these drugs and how they are used. We will see an increase of adverse events related to NSAIDs or acetaminophen as a result of the mad rush to get people off opioids. It is inevitable, according to Sean Mackey, chief pain medicine at Stanford University.
NSAIDs can cause bleeding and, with the exception of aspirin, may increase the risk of heart attacks or strokes. These dangers became more apparent in 2000, when a new type of NSAID, COX-2 inhibitors was released. This inhibits an enzyme called cyclooxygenase-2. Most NSAIDs block both COX-1 as well as COX-2 enzymes. They were designed to be gentler on the stomach, but they caused damage to the circulatory system. Two of these drugs were removed. Celecoxib (or Celebrex) is still available on the market. This led to increased scrutiny of non-aspirin NSAIDs and they were all found to have cardiovascular risks. The warnings made by the U.S. Food and Drug Administration about these dangers were increased in 2015. They are especially relevant for those with heart disease and risk factors. Christian Ruff, director at Brigham and Womens Hospital, Boston, says that Advil and Aleve (naproxen), are safe for heart patients if they twist their ankles or strain their backs. I advise patients to only use NSAIDs for short periods of time and to take the lowest possible dose to provide the pain relief they need.
NSAIDs have multiple effects on the cardiovascular system. They inhibit COX enzymes which are involved in tissue repair and blood clotting. Ruff says that they increase stroke and heart attack risk by encouraging clotting. They can slow down wound healing after a heart attack and promote fluid and salt retention which can overload the heart. Although Aspirin is not known to cause any of these problems, it can increase the risk of bleeding and is therefore not recommended for heart attacks prevention.
Risks to pregnant women are due to the impact on their kidneys. The FDA advised against using NSAIDs during pregnancy at any stage beyond 20 weeks. They can harm fetal kidneys, and thereby lead to low levels amniotic fluid. People with heart, kidney disease or pregnancy who are unable to take NSAIDs should consider paracetamol or acetaminophen. Unlike NSAIDs, this drug is not able to reduce inflammation and can be used for pain and fever. It is safe up to a threshold and dangerous above that, according to Erin Krebs, a University of Minnesota pain researcher and professor of medicine. Krebs believes it is crazy that the drug is found in over 600 products, such as flu and cold formulas. This makes it easy to get too high. Acetaminophen poisoning is now the leading reason Americans need a transplant.
These painkillers can be used with care and judicious usage. Mackey states that it is more difficult if you plan to use them for a long time. Mackey says that NSAIDs can be difficult to use for long periods of time. We monitor their blood work to ensure they are not taking them without food. Mackey will often recommend that patients try multiple options before settling on the one that works best. He points out that every thing we put in our bodies carries some risk. There is no free lunch.