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Head throbbing? Back aching? Arthritis flaring up? People in such plights ― and countless others ― almost universally respond the same way: pop a painkiller. Indeed, recent surveys show 1 in 3 Americans take over-the-counter pain medication daily and as many as 8 in 10 report reaching for it routinely. But how much do people really know about these seeming wonder drugs found in practically every home or office first-aid kid? In this episode, we explore the different types of painkillers, how to know which to take for your condition and when they do more harm than good.
Expert: Dr. William McKee, Internal Medicine
Interviewer: Todd Ackerman
Notable topics covered:
- The history of painkillers
- Acetaminophen, NSAIDs — which is right for your pain
- Interaction issues involving painkillers and prescription drugs
- Do some people just respond better to a certain type of painkiller?
- Side effects: The dangers of over-the-counter painkillers
- Are generics just as effective?
- Topical painkillers: All the benefits without the potential harms
- When are prescription painkillers appropriate?
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ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.
TODD ACKERMAN: I'm Todd Ackerman. I'm a former medical reporter, currently an editor at Houston Methodist.
ZACH: And Todd, do you use painkillers?
TODD: Occasionally. I'm not a big painkiller user. I have a sinus condition that I usually have some mild pressure in my forehead area, but -- I don't take it for that but some days, it gets more moderate to severe and then I'll take it.
ZACH: Yeah.
TODD: You?
ZACH: Only in certain situations. An aching that's going on for too long, or I'm really feeling a strong headache for example. But I try not to go to the medicine cabinet the first sign of trouble, right? I try to, like, let things play out and see if I really need to do that or not.
TODD: Yeah. How about when you've had, like, injur -- sports injuries?
ZACH: Yeah, I had knee surgery once in college and I took a lot of ibuprofen afterward. They said, "Hey, take this, you know, three times a day if you feel sore, and I was." And that was probably the most regular I've been on something like this as far as a schedule of any kind, any regularity.
TODD: Yeah. I'm kind of similar. I don't think I've ever been on anything that regular. There are times where my sinuses seem to bother me for a number of consecutive days. I get nervous when I take them for many days in a row.
ZACH: Yeah, you don't want to get too dependent on 'em or you don't wanna take too many, which is something we're gonna be talking about today as well.
TODD: Yes. But the thing that strikes me is when you go to the pharmacy or supermarket and you go down that aisle, just the bewildering array of options there are.
ZACH: Yeah. Like, there's something for literally everything.
TODD: Yes.
ZACH: Right?
TODD: Better too much than not enough.
ZACH: That's true. It's good to have choices, right?
TODD: Yes, exactly.
ZACH: But then you get decision fatigue, right? If you're in the aisle and you're looking around.
TODD: Yeah, it can be a tough decision, that's true. I'm also looking what has a coupon or something like that.
ZACH: There it is. Going for the... [Laughter] "What are the health concerns? I don't care. What's the cheapest?" right? But no, I mean, usually you're going in there for one specific thing, right? You know, you don't go in with like, "Well, I might have this or I might have," -- I don't stock up on potential injury, you know, medicine, I just go in when you need the one specific thing.
TODD: But do you know exactly what you need for that particular thing that you're feeling?
ZACH: That's -- well, I think I do until I go to the store to your point.
TODD: Yeah. That's what I'm saying.
ZACH: Yeah.
TODD: Well, if only we had someone who could break that down for us.
ZACH: If only we did, Todd. Who did we talk to about painkillers today?
TODD: We talked to Dr. William McKee, who's a Doctor of Internal Medicine at Houston Methodist.
[Sound effect plays to signal beginning of interview]
TODD: Welcome Dr. Mckee.
DR. WILLIAM MCKEE: Thank you. Thank you for having me this afternoon.
TODD: Good to have you on the podcast here to talk about painkillers, mostly over-the-counter. Very popular drug, is that -- would you say these are the most used drugs in America?
DR. MCKEE: Yeah. I saw one report state that there's over 500 over-the-counter variations or availability of some combination of anti-inflammatories or analgesics is another term we use. Whether it's the cold and cough medicines, headache medications, or aches and pains.
TODD: And aspirin was like the first wonder drug?
DR. MCKEE: Right. So, aspirin is extremely old. It was found to be used by the Sumerians 4,000 years ago. And of course, it became very popular in the early 1900s and 1800s. But yes, it's been around for a long time. It's one of those medications that by culture was used, but would it really be approved by a drug oversight company later on. But yes, it was the first one. And then, more and more research came out, which brought forth the non-steroidal anti-inflammatories like ibuprofen, and naproxen, and then acetaminophen.
TODD: Do you ever reflect on the popularity of painkillers? Just like, I mean, there's just a lot of pain out there I guess.
DR. MCKEE: Right. It is one of those things that it's part of our society. It's something you grew up around. And even more so, I guess as a father now, I'm much more around it 'cause you see it with kids. Whether all the different formulations they have, and how often we use it for something as small as teething with my newborn to -- or fevers that we have with young kids. So yes, it is something that is part, and then it can be also very controversial with the massive recall of Tylenol during the, I believe it was the 1980s when there was some contamination or poisoning of the Tylenol supply.
TODD: Can you just talk about the major types of over-the-counter painkillers and how they work?
DR. MCKEE: There are two main categories. There's the analgesic category or Tylenol, acetaminophen, and then there's the non-steroidal anti-inflammatory group, which includes ibuprofen, Advil, or Aleve, naproxen. Tylenol possesses analgesic and anti-fever properties, but lacks any anti-inflammatory effect. Whereas the non-steroidal anti-inflammatories do have an anti-inflammatory property as well as an anti-fever property by the receptors that it hits. These receptors modulate inflammatory markers that signal to the body that there's inflammation.
TODD: Generally, how effective are these painkillers? I mean, is there data showing that there's strong effectiveness for most kinds of pain whether it's headaches, lower back pain, toothaches, arthritis, neuropathy?
DR. MCKEE: Yes, absolutely. These do end up being part of many of the guidelines that we use in day-to-day medication due to their benefit. Acetaminophen in particular is extremely effective for headaches, extremely effective for fever, which generates pain and discomfort, and then we use it to augment the overall degree of pain people are experience. And then, with the non-steroidal anti-inflammatories, ibuprofen, naproxen, they are very effective for inflammation. Specifically if it's an acute strain or muscle damage associated with that, so. Weekend warrior, "I overdid it on the pickleball court," "I strained my back lifting something." The non-steroidals are our go-to for those conditions.
TODD: Are there any types of pain that they're just not that effective for?
DR. MCKEE: You mentioned earlier neuropathy. They're probably not very effective for neuropathy, which is more of a nerve mediated pain, and so there is a different class of medications for those. And then, depending on, like, an acute severe pain or post-surgical pain, there are roles for those, but that is some of the reasons why there's the stronger classes of drugs that we use in the hospital.
TODD: So, you mentioned some strong indications for some versus another, but is there also some element of, sort of, whatever works best for you? That it's a little bit of a crapshoot there, a personal thing of your body just seems to like one better than the other?
DR. MCKEE: Sure, sure. I think that's one of the biggest difference for -- some people prefer ibuprofen and some people prefer naproxen. In the subclass of non-steroidals, yes, there's definitely that. But there is some role for Tylenol. When we talk about pain, we like to talk about it on a scale of zero to ten. And we have found that Tylenol is very helpful in bringing down a level two or three degrees from seven to five or six to three. Now, there's even a product on the market that has both ibuprofen and Tylenol combined. There's definitely a wide range of mixing and matching them, yes.
TODD: I think Excedrin always works the best for me. And I don't know if that's because it's a combination of aspirin, and acetaminophen, and caffeine. How does the caffeine help?
DR. MCKEE: So, Excedrin that you're talking about is probably mostly used for headaches and migraines, and that is the current first line recommendation for headache and migraine. And the way it works, one of the pathologies for headache and migraine is vasodilation of the blood, raising pressure on the nerves in the brain. So, Excedrin with that combination, it's three different areas, and the caffeine causes vasoconstriction or the blood vessels to tighten up. And so, caffeine itself can be a headache reliever as well as causing headaches whenever people withdraw from it. So, there is a mixed bonus of that.
TODD: I don't get any caffeine normally, I don't drink coffee, I don't have Cokes or anything like that. So, maybe it's just that jolt it gives me that I don't normally ever have.
DR. MCKEE: Right. So, that probably is one of the ways it is helping with your headache. Headaches in particular are very interesting because there's also medication dependent headaches. And that's for the individuals who take Excedrin every day. And then, they start to become dependent or reliant on those medications. My overall philosophy, especially with pain or any other medications is trying to figure out a moderation or trying got use it as sparingly as possible.
TODD: Yeah. I mean, is the combination of aspirin and acetaminophen dangerous?
DR. MCKEE: With the way they work, aspirin is irreversible. So, once it binds to the COX receptor as well as platelets, yes, high doses of aspirin in certain individuals can be more dangerous, as well as the high amount of Tylenol. But no, you can use 'em together.
TODD: I get a little nervous when I take it for more than like one seven days in a row just 'cause it just -- it seems pretty powerful.
DR. MCKEE: Overall, the condition, yes. You can -- the way they work with that caffeine, yes, you can start to have rebound headache. That is one way that we try to caution people whenever they're using 'em for headaches in particular.
TODD: So, what are the dangers of over-the-counter painkillers generally? They all have potential side effects, right?
DR. MCKEE: So, acetaminophen is the one that we generally worry about liver toxicity. The daily dose limit is four grams. Most people have found that below three grams, and most docs treat to two grams per day. It does take quite a bit of time to take acetaminophen at very high levels to 'cause inflammation within the liver. But when you combine it with other things or if someone has underlying liver problems, then that would increase the risk of damage to the liver. So, in general, we caution people to stay under two grams per day. And there's different variations of Tylenol. There's now an eight-hour acetaminophen versus the four-to-six-hour version. Most of the maximum dosing is between 500 to 1,000 milligrams at a time. The non-steroidals definitely have a little more side effects, and part of it is the COX receptor that they're binding to. There's two types. There's one that moderates inflammation and then there's one that moderates in the lining of the stomach as well as on the kidney. So, we have high doses of non-steroidal anti-inflammatories end up irritating the stomach. And so, there's always a risk for forming ulcers, in the stomach or in other parts of the GI tract. And then, there's overall irritation to the kidneys. So, some of the more powerful non-steroidals will have people monitor their kidney function while using it.
TODD: But generally, you can take them chronically?
DR. MCKEE: Not the NSAIDs as much. We generally try to have people not take as much long-term. They also raise your blood pressure if taken long-term. And then, there's an increased risk of bleeding because of their interaction with the platelets in your blood.
TODD: And are there particular times to be particularly cautious? Certain health conditions, pregnancy, childhood?
DR. MCKEE: A lot of times, people are on blood thinning medications with cardiovascular, and so we're very cautious with that and the anti-inflammatories. Most, especially in the elderly population, we're getting more and more away from anti-inflammatories and having people use acetaminophen for arthritis. As an internist, we try to limit the amount. In pediatrics, we dose them based on weight, so that's one of the things we always have to monitor. But Tylenol is generally considered safe during pregnancy as well.
TODD: How about using more than one NSAID at once? I think there's one study that a lot of participants in it didn't know they were exceeding recommended limits because they didn't recognize that they were getting more than one.
DR. MCKEE: Yep. No, I -- that's definitely something that we focus on, patient education, trying to see. 'Cause a lot of times, people are prescribed a stronger one, or a prescription strength, non-steroidal, anti-inflammatory. And then, they're saying, "Well, I took this at 4 o'clock and then I took another one at 8 o'clock and I didn't get any better." And in general, that just increases the risk of the overall side effects. So, the irritation of the stomach or damage to the kidneys.
TODD: Some of this stuff is in other medications like cough medicine or anything like that?
DR. MCKEE: Yeah. So, one of the ways you've seen how they've really tried to limit was during the more recent opioid epidemic, all the formulations of acetaminophen with opioids, the FDA mandated a lower dosing, so they changed all the doses. So, people were taking one set of pills and a second acetaminophen. Each dosing trying to manage their pain. And so, they were getting above 4,000 milligrams per day, and the same thing with the anti-inflammatories, cough medicines. One way you probably can do it is when you do an oral and a topical, which is a little more balancing. The topical agents will be more local and not systemic.
TODD: Yeah. Well, let me -- I want to get to those in a bit. Is there some point in which you're using over-the-counter painkillers that they start to lose effectiveness? For me, it seems like I take one for about a week and I don't feel as much, and I lay off it for a while, and then I feel like I get more of it. Is that just my personal thing or is that a tendency that your immune system gets used to it?
DR. MCKEE: I think it's partly what you're trying to treat. So, if it is a chronic injury. So, if there is a form of arthritis that is established, and you see it by X-ray and you're like, "Alright, my shoulder's hurting." But if it's more of a strain, it should be very effective, and as you start to heal, the pain should improve. When it comes to acetaminophen and long-term pain, we're using it more and more. So, lots of people treat their chronic arthritis, and we're using the extended-release versions to try to limit their total per day. So, in some ways, yes. And like I said earlier about headaches, yes. There are certain pathologies or maladies that we have to gauge, whether this is something that's gonna be permanent or if it comes and goes.
TODD: What should people know about interactions with other medications? Even before we get to other medications. How about just taking baby aspirin for heart health as well as an NSAID, is that fine?
DR. MCKEE: I'm a member of the American College of Physicians. One of the things that they're really trying to emphasize is, is aspirin necessarily a heart health drug? And that's something we're trying to see. So, aspirin is indicated for secondary heart prevention if you have established vascular disease or heart disease. Is it as necessary for primary prevention of heart disease? And that, as a society and we're looking at overall long-term prevention, more and more of us are using less of it for heart health.
TODD: Yeah, I know it's pretty unsettled, but you still got a lot of people out there doing that, right?
DR. MCKEE: We do. And so, we're trying to limit their overall risk for bleeding from doing that. In the right patient, yes, you can take an aspirin a day and then a ibuprofen or a naproxen for an inflammatory pain, but is that something that we would want you to do every day? Probably not.
TODD: Are there any timing issues with that?
DR. MCKEE: Unfortunately, no. Aspirin is in your system for about seven days. And so, the longer you're on the aspirin, then you have to consider the non-steroidal anti-inflammatory.
TODD: And how about just pharmaceuticals generally, is there any interaction issues?
DR. MCKEE: Yes, there are some interactions. Whenever someone's on these more long-term, we try to protect the stomach. So, we have people take a proton pump inhibitor or a H2 blocker. Those are like famotidine, Pepcid or omeprazole, esomeprazole, which are some of the other over-the-counters. There are blood thinners. So, other heart patients that take blood thinners. Some may know 'em as Coumadin, warfarin or the newer agents, rivaroxaban. Those increase your risk for bleeding. The other one's clopidogrel for people who've had heart stents. Definitely those are ones that we try to stay away from. Another common drug, the regular steroids or prednisone, dexamethasone, those are other drugs that increase your risk for GI bleeds, so we try to not have people take both of those at the same time.
TODD: And are generics just as effective? I've always thought so, but I occasionally encounter a doctor who disagrees.
DR. MCKEE: There are certain drugs that there are, but in this class, with their over-the-counter, I believe the overall efficacy, the FDA did do a large-scale review and found that most of the over-the-counter generics versus brand there was about a 95% efficacy comparison. So, that 3-5% is well within a reasonable margin.
[Music to signal a brief interjection in the interview]
TODD: More with Dr. Mckee after the break.
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[Sound effect signals return to the interview]
TODD: Topical forms, are they often a better choice because there isn't the gut side effects?
DR. MCKEE: Absolutely, they're great. For a long time, Voltaren was a brand name and prescription, but over the last ten years, it's become over-the-counter, especially with large joints. We found it very helpful with knees, elbows, and hands.
TODD: How about shoulders?
DR. MCKEE: You can use it for shoulder. Shoulder's a little more complex because of the muscles involved.
TODD: It mostly works on the joints?
DR. MCKEE: Correct. It's very good. Lots of data showing that it's very effective for knee arthritis.
TODD: And it is mostly arthritis or just like any inflammation in those?
DR. MCKEE: Mostly arthritis, yeah.
TODD: How about lidocaine creams, patches?
DR. MCKEE: So, that is more of a numbing agent, and so that will be very short-term benefit, not really anything therapeutic.
TODD: Same with Bengay type products?
DR. MCKEE: Yup. The benzocaine and lidocaine are both topical numbing. Those definitely have a role, and we use 'em for a great example is sometimes with shingles outbreaks, skin outbreaks. But those are good modulators. Probably more helpful with some of the pain that is derived from nerves versus inflammation.
TODD: How about arnica? Do you know that homeopathic, you see that pretty mainstream now.
DR. MCKEE: It is something that's available, and I think it's just -- as with most supplements, that's gonna be a person by person. Some people receive benefits, some people don't.
TODD: How about herbal medications? I know of turmeric, ginger.
DR. MCKEE: Turmeric is one of the oldest anti-inflammatories going back many millennium. It is still very helpful. We do have to watch out if it does irritate the stomach as much, but we can use it. I endorse patients using it. Yeah, I think it has been helpful.
TODD: You're generally pretty open to trying alternatives if you're not getting relief otherwise?
DR. MCKEE: Yeah. That's been a very common question recently. With another type of topical like some of the cannabinoids. So, we see lots of questions on is really some of the first CBD came into the market, now some of the other ones are. But yeah, they're -- again, it is patient by patient experience. Some people swear by CBD topicals, and some say it doesn't do anything for them.
TODD: What kind of data is emerging on that note?
DR. MCKEE: They've gotta do a lot more. My understanding, especially on that data is as each state changes their regulations, some of the universities can do more research but federally, there's still difficulty getting a organized data.
TODD: So, when is it time for the prescription painkillers like the COX -- the NSAIDs?
DR. MCKEE: When I'm thinking of using those, generally with a younger healthy person and it's short-term, I don't think about the prescription. When we see individuals that have multiple problems including chronic kidney disease, chronic liver disease, or heart problems, then we have to say, "Okay, is this something that we have the option to do a more selective? Meloxicam is one of the stronger ones and it is non-selective, and then you've got celecoxib, which is a selective for just the second enzyme, and so, it protects the stomach more. So, if someone does have a history of bleeding or intolerance to the stronger anti-inflammatories, then we bring on one of the other ones.
TODD: I assume those are even more dangerous potentially?
DR. MCKEE: Well, I think what you're referring to is some of the more opioid-based or...
TODD: Well, even the COX-2 though, they don't have potential for -- I mean just by nature of being a pharmaceutical having to go through all that testing.
DR. MCKEE: Since it went generic, its use overall has increased, it's affordable. And the overall not having that GI bleeding risk, it is used fairly common. It's used perioperatively for pain control. So, sometimes surgeons prescribe it before they do surgeries to try to limit overall pain. So, some of these prescription ones, while still requiring prescription, I think probably are -- can be a little safer than some of these other non-prescription ones or over-the-counter.
TODD: So, if they're safer, why wouldn't they go over-the-counter too?
DR. MCKEE: It's just -- it's gonna take time. I think it's more of how the overall FDA protocols, but I'm sure some of these will eventually go over-the-counter.
TODD: Opioids as you mentioned, often for surgical procedures.
DR. MCKEE: So, opioids right now are mostly reserved for acute care pain, post-surgical, or trauma. And then, also included for long-term cancer care. One of the big changes is the longer you treat an individual with those medications, the less the benefit that they provide, and the body becomes tolerant to 'em. And so, there has been this entire revamp of pain management over the last ten years to really reserve new prescriptions for opioids to something like a kidney stone, or Tylenol with codeine is oftentimes, some of the strongest medicine prescribed after a C-section or an appendix removal, or a hernia repair. And again, these are all very short-term prescriptions so that the body doesn't start to become sensitized.
TODD: And how much of an issue was there with organ damage? I mean, I'm certainly aware of the dependence issues. But seems like whenever I've had them with a surgical procedure, the biggest concern they always warn about is things like constipation, nausea, drowsiness.
DR. MCKEE: Yeah, absolutely. The constipation is a direct cause by the drug. The contractions that your bowels are supposed to have normally almost stop due to the opioids. So, it's not if, it's you will become constipated when you take 'em.
TODD: How do people get addicted with that?
DR. MCKEE: Management of a heroin addict is they become heroin addicts, and they have to actually stop the heroin so they can go to the bathroom. I haven't seen it in a decade, but when I was in residency, I managed several patients who had that problem. So, the power on the brain is more...
TODD: Yeah.
DR. MCKEE: Can be more powerful than on the bowels.
TODD: Yeah. Interesting.
DR. MCKEE: One of the reasons they become so popular was that there wasn't many long-term issues with them, except the addictive properties and kind of the GI side effects.
TODD: Okay. Alright, well that's mostly what I had. Is there anything I didn't ask about that you would want to talk about?
DR. MCKEE: There is a couple that have come out recently. We haven't seen 'em mainstream but just January, the FDA did approve a new drug that's non-opioid and non-steroidal. The drug's name is Suzetrigine.
TODD: Suzie what?
DR. MCKEE: Suzetrigine or Journavx, which is a first-in-class non-opioid analgesic to treat moderate to severe acute pain. So, it's one of those things that as a provider, once it becomes mainstream and more doctors available, we look forward to learning more about it and seeing how it works because if there is something we can offer, that's non-addictive, controls moderate to severe pain more so than acetaminophen. Those are options that patients should request.
TODD: The new drug you mentioned is a prescription that's in a doctor's arsenal now if over-the-counter...
DR. MCKEE: Correct.
TODD: Painkillers aren't doing enough.
DR. MCKEE: Right. TODD: Is it being prescribed much yet? Have you prescribed it to patients?
DR. MCKEE: I haven't. And partly, it's probably whether or not insurance is covering it. So, that's one of the limitations. It only came out in February, so generally it takes three to six months for formularies to add 'em and then see whether it's the surgeons or the internists are offering it.
TODD: A lot of excitement in the medical community about it?
DR. MCKEE: Yeah, absolutely. I was talking to one of my colleagues about the podcast and they said, "Well, make sure to mention the new one coming now," so...
TODD: I hadn't heard of that. That's interesting. Is there any sort of take away that you would hope to leave listeners with about painkillers?
DR. MCKEE: Sure. So, the over-the-counter medicines are great, they work well. The main thing, and I tell this to all my patients, in moderation. So, if it is, depending on what your goal or what you're treating, if you are gonna take it for more than seven to ten days, that's when you need to ask your doctor, "Is this okay?" Teaming up with your doctor, come up with a plan because the longer you do have pain, then there needs to be other alternatives whether it's physical therapy, further investigation like MRIs, or some of the nontraditional practices that are available now.
TODD: I appreciate you talking with us, I mean, just a vast array of stuff out there, so it's always good to know more about it.
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ZACH: So, Todd, we talked a lot about painkillers there. What are your biggest takeaways from that conversation? TODD: Well, not really a profound takeaway, but I did want to say that the fact that there are 500 variations of painkillers kind of blew me away. I mean, I said at the beginning that it seems bewildering sometimes there, but I had no idea it was a number like 500.
ZACH: No, you put a number like that on it, it really puts it in perspective.
TODD: Of course, that includes cough medicine and all sorts of things.
ZACH: Right. Which was interesting. I never really thought about those as -- you guys were talking about the different, you know, the different kinds of painkillers. I think the pills you take when you have a headache, or your muscles are sore, something like that. I don't think about, you know, cough syrup. But I mean that does qualify.
TODD: Right. But to me the most enlightening thing was the part where we talked about topical painkillers.
ZACH: Yeah, yeah. I mean, that was something I was unfamiliar with, and I assume a lot of our listeners are unfamiliar with as well.
TODD: Yeah, I had just learned of it just a few weeks before 'cause I had shoulder surgery, and my surgeon recommended that I might try that. So, I've been using it. I feel like I can use it as much as I want because there's no danger that it's gonna start damaging my internal organs.
ZACH: Yeah no, that is a fear a lot of people have about painkillers, yeah.
TODD: Because of the shoulder surgery, I have a lot of inflammation, and so I took to taking naproxen pretty regularly, and that makes me very nervous taking it day in and day out for, you know, a period of weeks.
ZACH: What makes you so nervous about it? Like the dependency factor or the potential –
TODD: No, no, that it's -- the sustained use of it can cause kidney damage. I think it's people who pop 'em a lot more still than me, but it's still when you're doing it twice a day for a number of weeks in a row, I was happy to find an alternative to that.
ZACH: That's not a fear that I have because I never really take them, but I guess if you were someone who was kinda routinely taking them, you start to think, "Oh man, maybe this is too much." But as literally every topic we talk about on this podcast, what's the answer? Moderation, right?
TODD: I thought it was a healthy diet, but yes. [Laughter]
ZACH: The Mediterranean diet, number one. Moderation, number two.
TODD: Yes, that's true.
ZACH: Alright, well that's gonna do it for this episode of On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings. So, until next time, stay tuned and stay healthy.
TODD ACKERMAN: I'm Todd Ackerman. I'm a former medical reporter, currently an editor at Houston Methodist.
ZACH: And Todd, do you use painkillers?
TODD: Occasionally. I'm not a big painkiller user. I have a sinus condition that I usually have some mild pressure in my forehead area, but -- I don't take it for that but some days, it gets more moderate to severe and then I'll take it.
ZACH: Yeah.
TODD: You?
ZACH: Only in certain situations. An aching that's going on for too long, or I'm really feeling a strong headache for example. But I try not to go to the medicine cabinet the first sign of trouble, right? I try to, like, let things play out and see if I really need to do that or not.
TODD: Yeah. How about when you've had, like, injur -- sports injuries?
ZACH: Yeah, I had knee surgery once in college and I took a lot of ibuprofen afterward. They said, "Hey, take this, you know, three times a day if you feel sore, and I was." And that was probably the most regular I've been on something like this as far as a schedule of any kind, any regularity.
TODD: Yeah. I'm kind of similar. I don't think I've ever been on anything that regular. There are times where my sinuses seem to bother me for a number of consecutive days. I get nervous when I take them for many days in a row.
ZACH: Yeah, you don't want to get too dependent on 'em or you don't wanna take too many, which is something we're gonna be talking about today as well.
TODD: Yes. But the thing that strikes me is when you go to the pharmacy or supermarket and you go down that aisle, just the bewildering array of options there are.
ZACH: Yeah. Like, there's something for literally everything.
TODD: Yes.
ZACH: Right?
TODD: Better too much than not enough.
ZACH: That's true. It's good to have choices, right?
TODD: Yes, exactly.
ZACH: But then you get decision fatigue, right? If you're in the aisle and you're looking around.
TODD: Yeah, it can be a tough decision, that's true. I'm also looking what has a coupon or something like that.
ZACH: There it is. Going for the... [Laughter] "What are the health concerns? I don't care. What's the cheapest?" right? But no, I mean, usually you're going in there for one specific thing, right? You know, you don't go in with like, "Well, I might have this or I might have," -- I don't stock up on potential injury, you know, medicine, I just go in when you need the one specific thing.
TODD: But do you know exactly what you need for that particular thing that you're feeling?
ZACH: That's -- well, I think I do until I go to the store to your point.
TODD: Yeah. That's what I'm saying.
ZACH: Yeah.
TODD: Well, if only we had someone who could break that down for us.
ZACH: If only we did, Todd. Who did we talk to about painkillers today?
TODD: We talked to Dr. William McKee, who's a Doctor of Internal Medicine at Houston Methodist.
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TODD: Welcome Dr. Mckee.
DR. WILLIAM MCKEE: Thank you. Thank you for having me this afternoon.
TODD: Good to have you on the podcast here to talk about painkillers, mostly over-the-counter. Very popular drug, is that -- would you say these are the most used drugs in America?
DR. MCKEE: Yeah. I saw one report state that there's over 500 over-the-counter variations or availability of some combination of anti-inflammatories or analgesics is another term we use. Whether it's the cold and cough medicines, headache medications, or aches and pains.
TODD: And aspirin was like the first wonder drug?
DR. MCKEE: Right. So, aspirin is extremely old. It was found to be used by the Sumerians 4,000 years ago. And of course, it became very popular in the early 1900s and 1800s. But yes, it's been around for a long time. It's one of those medications that by culture was used, but would it really be approved by a drug oversight company later on. But yes, it was the first one. And then, more and more research came out, which brought forth the non-steroidal anti-inflammatories like ibuprofen, and naproxen, and then acetaminophen.
TODD: Do you ever reflect on the popularity of painkillers? Just like, I mean, there's just a lot of pain out there I guess.
DR. MCKEE: Right. It is one of those things that it's part of our society. It's something you grew up around. And even more so, I guess as a father now, I'm much more around it 'cause you see it with kids. Whether all the different formulations they have, and how often we use it for something as small as teething with my newborn to -- or fevers that we have with young kids. So yes, it is something that is part, and then it can be also very controversial with the massive recall of Tylenol during the, I believe it was the 1980s when there was some contamination or poisoning of the Tylenol supply.
TODD: Can you just talk about the major types of over-the-counter painkillers and how they work?
DR. MCKEE: There are two main categories. There's the analgesic category or Tylenol, acetaminophen, and then there's the non-steroidal anti-inflammatory group, which includes ibuprofen, Advil, or Aleve, naproxen. Tylenol possesses analgesic and anti-fever properties, but lacks any anti-inflammatory effect. Whereas the non-steroidal anti-inflammatories do have an anti-inflammatory property as well as an anti-fever property by the receptors that it hits. These receptors modulate inflammatory markers that signal to the body that there's inflammation.
TODD: Generally, how effective are these painkillers? I mean, is there data showing that there's strong effectiveness for most kinds of pain whether it's headaches, lower back pain, toothaches, arthritis, neuropathy?
DR. MCKEE: Yes, absolutely. These do end up being part of many of the guidelines that we use in day-to-day medication due to their benefit. Acetaminophen in particular is extremely effective for headaches, extremely effective for fever, which generates pain and discomfort, and then we use it to augment the overall degree of pain people are experience. And then, with the non-steroidal anti-inflammatories, ibuprofen, naproxen, they are very effective for inflammation. Specifically if it's an acute strain or muscle damage associated with that, so. Weekend warrior, "I overdid it on the pickleball court," "I strained my back lifting something." The non-steroidals are our go-to for those conditions.
TODD: Are there any types of pain that they're just not that effective for?
DR. MCKEE: You mentioned earlier neuropathy. They're probably not very effective for neuropathy, which is more of a nerve mediated pain, and so there is a different class of medications for those. And then, depending on, like, an acute severe pain or post-surgical pain, there are roles for those, but that is some of the reasons why there's the stronger classes of drugs that we use in the hospital.
TODD: So, you mentioned some strong indications for some versus another, but is there also some element of, sort of, whatever works best for you? That it's a little bit of a crapshoot there, a personal thing of your body just seems to like one better than the other?
DR. MCKEE: Sure, sure. I think that's one of the biggest difference for -- some people prefer ibuprofen and some people prefer naproxen. In the subclass of non-steroidals, yes, there's definitely that. But there is some role for Tylenol. When we talk about pain, we like to talk about it on a scale of zero to ten. And we have found that Tylenol is very helpful in bringing down a level two or three degrees from seven to five or six to three. Now, there's even a product on the market that has both ibuprofen and Tylenol combined. There's definitely a wide range of mixing and matching them, yes.
TODD: I think Excedrin always works the best for me. And I don't know if that's because it's a combination of aspirin, and acetaminophen, and caffeine. How does the caffeine help?
DR. MCKEE: So, Excedrin that you're talking about is probably mostly used for headaches and migraines, and that is the current first line recommendation for headache and migraine. And the way it works, one of the pathologies for headache and migraine is vasodilation of the blood, raising pressure on the nerves in the brain. So, Excedrin with that combination, it's three different areas, and the caffeine causes vasoconstriction or the blood vessels to tighten up. And so, caffeine itself can be a headache reliever as well as causing headaches whenever people withdraw from it. So, there is a mixed bonus of that.
TODD: I don't get any caffeine normally, I don't drink coffee, I don't have Cokes or anything like that. So, maybe it's just that jolt it gives me that I don't normally ever have.
DR. MCKEE: Right. So, that probably is one of the ways it is helping with your headache. Headaches in particular are very interesting because there's also medication dependent headaches. And that's for the individuals who take Excedrin every day. And then, they start to become dependent or reliant on those medications. My overall philosophy, especially with pain or any other medications is trying to figure out a moderation or trying got use it as sparingly as possible.
TODD: Yeah. I mean, is the combination of aspirin and acetaminophen dangerous?
DR. MCKEE: With the way they work, aspirin is irreversible. So, once it binds to the COX receptor as well as platelets, yes, high doses of aspirin in certain individuals can be more dangerous, as well as the high amount of Tylenol. But no, you can use 'em together.
TODD: I get a little nervous when I take it for more than like one seven days in a row just 'cause it just -- it seems pretty powerful.
DR. MCKEE: Overall, the condition, yes. You can -- the way they work with that caffeine, yes, you can start to have rebound headache. That is one way that we try to caution people whenever they're using 'em for headaches in particular.
TODD: So, what are the dangers of over-the-counter painkillers generally? They all have potential side effects, right?
DR. MCKEE: So, acetaminophen is the one that we generally worry about liver toxicity. The daily dose limit is four grams. Most people have found that below three grams, and most docs treat to two grams per day. It does take quite a bit of time to take acetaminophen at very high levels to 'cause inflammation within the liver. But when you combine it with other things or if someone has underlying liver problems, then that would increase the risk of damage to the liver. So, in general, we caution people to stay under two grams per day. And there's different variations of Tylenol. There's now an eight-hour acetaminophen versus the four-to-six-hour version. Most of the maximum dosing is between 500 to 1,000 milligrams at a time. The non-steroidals definitely have a little more side effects, and part of it is the COX receptor that they're binding to. There's two types. There's one that moderates inflammation and then there's one that moderates in the lining of the stomach as well as on the kidney. So, we have high doses of non-steroidal anti-inflammatories end up irritating the stomach. And so, there's always a risk for forming ulcers, in the stomach or in other parts of the GI tract. And then, there's overall irritation to the kidneys. So, some of the more powerful non-steroidals will have people monitor their kidney function while using it.
TODD: But generally, you can take them chronically?
DR. MCKEE: Not the NSAIDs as much. We generally try to have people not take as much long-term. They also raise your blood pressure if taken long-term. And then, there's an increased risk of bleeding because of their interaction with the platelets in your blood.
TODD: And are there particular times to be particularly cautious? Certain health conditions, pregnancy, childhood?
DR. MCKEE: A lot of times, people are on blood thinning medications with cardiovascular, and so we're very cautious with that and the anti-inflammatories. Most, especially in the elderly population, we're getting more and more away from anti-inflammatories and having people use acetaminophen for arthritis. As an internist, we try to limit the amount. In pediatrics, we dose them based on weight, so that's one of the things we always have to monitor. But Tylenol is generally considered safe during pregnancy as well.
TODD: How about using more than one NSAID at once? I think there's one study that a lot of participants in it didn't know they were exceeding recommended limits because they didn't recognize that they were getting more than one.
DR. MCKEE: Yep. No, I -- that's definitely something that we focus on, patient education, trying to see. 'Cause a lot of times, people are prescribed a stronger one, or a prescription strength, non-steroidal, anti-inflammatory. And then, they're saying, "Well, I took this at 4 o'clock and then I took another one at 8 o'clock and I didn't get any better." And in general, that just increases the risk of the overall side effects. So, the irritation of the stomach or damage to the kidneys.
TODD: Some of this stuff is in other medications like cough medicine or anything like that?
DR. MCKEE: Yeah. So, one of the ways you've seen how they've really tried to limit was during the more recent opioid epidemic, all the formulations of acetaminophen with opioids, the FDA mandated a lower dosing, so they changed all the doses. So, people were taking one set of pills and a second acetaminophen. Each dosing trying to manage their pain. And so, they were getting above 4,000 milligrams per day, and the same thing with the anti-inflammatories, cough medicines. One way you probably can do it is when you do an oral and a topical, which is a little more balancing. The topical agents will be more local and not systemic.
TODD: Yeah. Well, let me -- I want to get to those in a bit. Is there some point in which you're using over-the-counter painkillers that they start to lose effectiveness? For me, it seems like I take one for about a week and I don't feel as much, and I lay off it for a while, and then I feel like I get more of it. Is that just my personal thing or is that a tendency that your immune system gets used to it?
DR. MCKEE: I think it's partly what you're trying to treat. So, if it is a chronic injury. So, if there is a form of arthritis that is established, and you see it by X-ray and you're like, "Alright, my shoulder's hurting." But if it's more of a strain, it should be very effective, and as you start to heal, the pain should improve. When it comes to acetaminophen and long-term pain, we're using it more and more. So, lots of people treat their chronic arthritis, and we're using the extended-release versions to try to limit their total per day. So, in some ways, yes. And like I said earlier about headaches, yes. There are certain pathologies or maladies that we have to gauge, whether this is something that's gonna be permanent or if it comes and goes.
TODD: What should people know about interactions with other medications? Even before we get to other medications. How about just taking baby aspirin for heart health as well as an NSAID, is that fine?
DR. MCKEE: I'm a member of the American College of Physicians. One of the things that they're really trying to emphasize is, is aspirin necessarily a heart health drug? And that's something we're trying to see. So, aspirin is indicated for secondary heart prevention if you have established vascular disease or heart disease. Is it as necessary for primary prevention of heart disease? And that, as a society and we're looking at overall long-term prevention, more and more of us are using less of it for heart health.
TODD: Yeah, I know it's pretty unsettled, but you still got a lot of people out there doing that, right?
DR. MCKEE: We do. And so, we're trying to limit their overall risk for bleeding from doing that. In the right patient, yes, you can take an aspirin a day and then a ibuprofen or a naproxen for an inflammatory pain, but is that something that we would want you to do every day? Probably not.
TODD: Are there any timing issues with that?
DR. MCKEE: Unfortunately, no. Aspirin is in your system for about seven days. And so, the longer you're on the aspirin, then you have to consider the non-steroidal anti-inflammatory.
TODD: And how about just pharmaceuticals generally, is there any interaction issues?
DR. MCKEE: Yes, there are some interactions. Whenever someone's on these more long-term, we try to protect the stomach. So, we have people take a proton pump inhibitor or a H2 blocker. Those are like famotidine, Pepcid or omeprazole, esomeprazole, which are some of the other over-the-counters. There are blood thinners. So, other heart patients that take blood thinners. Some may know 'em as Coumadin, warfarin or the newer agents, rivaroxaban. Those increase your risk for bleeding. The other one's clopidogrel for people who've had heart stents. Definitely those are ones that we try to stay away from. Another common drug, the regular steroids or prednisone, dexamethasone, those are other drugs that increase your risk for GI bleeds, so we try to not have people take both of those at the same time.
TODD: And are generics just as effective? I've always thought so, but I occasionally encounter a doctor who disagrees.
DR. MCKEE: There are certain drugs that there are, but in this class, with their over-the-counter, I believe the overall efficacy, the FDA did do a large-scale review and found that most of the over-the-counter generics versus brand there was about a 95% efficacy comparison. So, that 3-5% is well within a reasonable margin.
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TODD: More with Dr. Mckee after the break.
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TODD: Topical forms, are they often a better choice because there isn't the gut side effects?
DR. MCKEE: Absolutely, they're great. For a long time, Voltaren was a brand name and prescription, but over the last ten years, it's become over-the-counter, especially with large joints. We found it very helpful with knees, elbows, and hands.
TODD: How about shoulders?
DR. MCKEE: You can use it for shoulder. Shoulder's a little more complex because of the muscles involved.
TODD: It mostly works on the joints?
DR. MCKEE: Correct. It's very good. Lots of data showing that it's very effective for knee arthritis.
TODD: And it is mostly arthritis or just like any inflammation in those?
DR. MCKEE: Mostly arthritis, yeah.
TODD: How about lidocaine creams, patches?
DR. MCKEE: So, that is more of a numbing agent, and so that will be very short-term benefit, not really anything therapeutic.
TODD: Same with Bengay type products?
DR. MCKEE: Yup. The benzocaine and lidocaine are both topical numbing. Those definitely have a role, and we use 'em for a great example is sometimes with shingles outbreaks, skin outbreaks. But those are good modulators. Probably more helpful with some of the pain that is derived from nerves versus inflammation.
TODD: How about arnica? Do you know that homeopathic, you see that pretty mainstream now.
DR. MCKEE: It is something that's available, and I think it's just -- as with most supplements, that's gonna be a person by person. Some people receive benefits, some people don't.
TODD: How about herbal medications? I know of turmeric, ginger.
DR. MCKEE: Turmeric is one of the oldest anti-inflammatories going back many millennium. It is still very helpful. We do have to watch out if it does irritate the stomach as much, but we can use it. I endorse patients using it. Yeah, I think it has been helpful.
TODD: You're generally pretty open to trying alternatives if you're not getting relief otherwise?
DR. MCKEE: Yeah. That's been a very common question recently. With another type of topical like some of the cannabinoids. So, we see lots of questions on is really some of the first CBD came into the market, now some of the other ones are. But yeah, they're -- again, it is patient by patient experience. Some people swear by CBD topicals, and some say it doesn't do anything for them.
TODD: What kind of data is emerging on that note?
DR. MCKEE: They've gotta do a lot more. My understanding, especially on that data is as each state changes their regulations, some of the universities can do more research but federally, there's still difficulty getting a organized data.
TODD: So, when is it time for the prescription painkillers like the COX -- the NSAIDs?
DR. MCKEE: When I'm thinking of using those, generally with a younger healthy person and it's short-term, I don't think about the prescription. When we see individuals that have multiple problems including chronic kidney disease, chronic liver disease, or heart problems, then we have to say, "Okay, is this something that we have the option to do a more selective? Meloxicam is one of the stronger ones and it is non-selective, and then you've got celecoxib, which is a selective for just the second enzyme, and so, it protects the stomach more. So, if someone does have a history of bleeding or intolerance to the stronger anti-inflammatories, then we bring on one of the other ones.
TODD: I assume those are even more dangerous potentially?
DR. MCKEE: Well, I think what you're referring to is some of the more opioid-based or...
TODD: Well, even the COX-2 though, they don't have potential for -- I mean just by nature of being a pharmaceutical having to go through all that testing.
DR. MCKEE: Since it went generic, its use overall has increased, it's affordable. And the overall not having that GI bleeding risk, it is used fairly common. It's used perioperatively for pain control. So, sometimes surgeons prescribe it before they do surgeries to try to limit overall pain. So, some of these prescription ones, while still requiring prescription, I think probably are -- can be a little safer than some of these other non-prescription ones or over-the-counter.
TODD: So, if they're safer, why wouldn't they go over-the-counter too?
DR. MCKEE: It's just -- it's gonna take time. I think it's more of how the overall FDA protocols, but I'm sure some of these will eventually go over-the-counter.
TODD: Opioids as you mentioned, often for surgical procedures.
DR. MCKEE: So, opioids right now are mostly reserved for acute care pain, post-surgical, or trauma. And then, also included for long-term cancer care. One of the big changes is the longer you treat an individual with those medications, the less the benefit that they provide, and the body becomes tolerant to 'em. And so, there has been this entire revamp of pain management over the last ten years to really reserve new prescriptions for opioids to something like a kidney stone, or Tylenol with codeine is oftentimes, some of the strongest medicine prescribed after a C-section or an appendix removal, or a hernia repair. And again, these are all very short-term prescriptions so that the body doesn't start to become sensitized.
TODD: And how much of an issue was there with organ damage? I mean, I'm certainly aware of the dependence issues. But seems like whenever I've had them with a surgical procedure, the biggest concern they always warn about is things like constipation, nausea, drowsiness.
DR. MCKEE: Yeah, absolutely. The constipation is a direct cause by the drug. The contractions that your bowels are supposed to have normally almost stop due to the opioids. So, it's not if, it's you will become constipated when you take 'em.
TODD: How do people get addicted with that?
DR. MCKEE: Management of a heroin addict is they become heroin addicts, and they have to actually stop the heroin so they can go to the bathroom. I haven't seen it in a decade, but when I was in residency, I managed several patients who had that problem. So, the power on the brain is more...
TODD: Yeah.
DR. MCKEE: Can be more powerful than on the bowels.
TODD: Yeah. Interesting.
DR. MCKEE: One of the reasons they become so popular was that there wasn't many long-term issues with them, except the addictive properties and kind of the GI side effects.
TODD: Okay. Alright, well that's mostly what I had. Is there anything I didn't ask about that you would want to talk about?
DR. MCKEE: There is a couple that have come out recently. We haven't seen 'em mainstream but just January, the FDA did approve a new drug that's non-opioid and non-steroidal. The drug's name is Suzetrigine.
TODD: Suzie what?
DR. MCKEE: Suzetrigine or Journavx, which is a first-in-class non-opioid analgesic to treat moderate to severe acute pain. So, it's one of those things that as a provider, once it becomes mainstream and more doctors available, we look forward to learning more about it and seeing how it works because if there is something we can offer, that's non-addictive, controls moderate to severe pain more so than acetaminophen. Those are options that patients should request.
TODD: The new drug you mentioned is a prescription that's in a doctor's arsenal now if over-the-counter...
DR. MCKEE: Correct.
TODD: Painkillers aren't doing enough.
DR. MCKEE: Right. TODD: Is it being prescribed much yet? Have you prescribed it to patients?
DR. MCKEE: I haven't. And partly, it's probably whether or not insurance is covering it. So, that's one of the limitations. It only came out in February, so generally it takes three to six months for formularies to add 'em and then see whether it's the surgeons or the internists are offering it.
TODD: A lot of excitement in the medical community about it?
DR. MCKEE: Yeah, absolutely. I was talking to one of my colleagues about the podcast and they said, "Well, make sure to mention the new one coming now," so...
TODD: I hadn't heard of that. That's interesting. Is there any sort of take away that you would hope to leave listeners with about painkillers?
DR. MCKEE: Sure. So, the over-the-counter medicines are great, they work well. The main thing, and I tell this to all my patients, in moderation. So, if it is, depending on what your goal or what you're treating, if you are gonna take it for more than seven to ten days, that's when you need to ask your doctor, "Is this okay?" Teaming up with your doctor, come up with a plan because the longer you do have pain, then there needs to be other alternatives whether it's physical therapy, further investigation like MRIs, or some of the nontraditional practices that are available now.
TODD: I appreciate you talking with us, I mean, just a vast array of stuff out there, so it's always good to know more about it.
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ZACH: So, Todd, we talked a lot about painkillers there. What are your biggest takeaways from that conversation? TODD: Well, not really a profound takeaway, but I did want to say that the fact that there are 500 variations of painkillers kind of blew me away. I mean, I said at the beginning that it seems bewildering sometimes there, but I had no idea it was a number like 500.
ZACH: No, you put a number like that on it, it really puts it in perspective.
TODD: Of course, that includes cough medicine and all sorts of things.
ZACH: Right. Which was interesting. I never really thought about those as -- you guys were talking about the different, you know, the different kinds of painkillers. I think the pills you take when you have a headache, or your muscles are sore, something like that. I don't think about, you know, cough syrup. But I mean that does qualify.
TODD: Right. But to me the most enlightening thing was the part where we talked about topical painkillers.
ZACH: Yeah, yeah. I mean, that was something I was unfamiliar with, and I assume a lot of our listeners are unfamiliar with as well.
TODD: Yeah, I had just learned of it just a few weeks before 'cause I had shoulder surgery, and my surgeon recommended that I might try that. So, I've been using it. I feel like I can use it as much as I want because there's no danger that it's gonna start damaging my internal organs.
ZACH: Yeah no, that is a fear a lot of people have about painkillers, yeah.
TODD: Because of the shoulder surgery, I have a lot of inflammation, and so I took to taking naproxen pretty regularly, and that makes me very nervous taking it day in and day out for, you know, a period of weeks.
ZACH: What makes you so nervous about it? Like the dependency factor or the potential –
TODD: No, no, that it's -- the sustained use of it can cause kidney damage. I think it's people who pop 'em a lot more still than me, but it's still when you're doing it twice a day for a number of weeks in a row, I was happy to find an alternative to that.
ZACH: That's not a fear that I have because I never really take them, but I guess if you were someone who was kinda routinely taking them, you start to think, "Oh man, maybe this is too much." But as literally every topic we talk about on this podcast, what's the answer? Moderation, right?
TODD: I thought it was a healthy diet, but yes. [Laughter]
ZACH: The Mediterranean diet, number one. Moderation, number two.
TODD: Yes, that's true.
ZACH: Alright, well that's gonna do it for this episode of On Health with Houston Methodist. Be sure to share, like, and subscribe wherever you get your podcasts. We drop episodes Tuesday mornings. So, until next time, stay tuned and stay healthy.
