Pain Pills and Potions

No two people suffer pain alike. Some do it stoically, some do it sympathetically, and some do it loudly, but almost all of us do it with a pill. Pain relief medication is a $1.7 billion-dollar-a-year business, but that doesn’t begin_to suggest the size of the entire pain market. According to data circulated by the makers of analgesics, nearly one third of all Americans have persistent or recurrent chronic pain. Each year such pain costs an estimated $80 to $90 billion in doctors’ fees, drugs, compensation, and litigation and is responsible for the loss of 700 million workdays.

Pain is perhaps the most personal of all experiences. lts impact is intimately intertwined with an individual’s emotions, moods, upbringing, and general outlook on life. My trying to tell you about my pain is an approximation at best, an exercise in futility at worst. For this reason alone, discussing pain and its management is a complicated task. Throw in the fact that most of our information about pain comes to us from today’s multibillion-dollar corporate pill peddlers and one begins to appreciate the benefits of arguing something a little more cut and dried—like politics or religion. As it relates to sports medicine in general and knee pain in particular, however, pain relief does become a slightly more manageable discussion topic. But only slightly.

The first problem is the psychological component. People who are athletically active—not just athletes, but also people who participate in recreational sports and activities—often believe that an admission of pain is tantamount to failure. Less extreme views, which consider pain an admission of imperfection or the price for
play, are equally unhealthy. Pain is the body’s alarm system. Shutting off the alarm, without finding out what triggered the alert in the first place, is both foolish and dangerous. By tuming off the pain which is your body’s way of saying “Hey, there’s something wrong down here!”-—you can take a minor knee problem and turn it into an activity-stopping, life-altering injury.

Another, more complicated problem is determining what’s causing the pain. In the case of the knee, we’ve discussed at length in this book the dozens of factors that play a role in the problems and symptoms associated with knee pain. The best rule of thumb for pill poppers is, if pain persists beyond three days of self-medication, get a medical examination.

Of course if you are self-medicating, you need something to medicate yourself with, and manufacturers have certainly stepped in to ‘offer you relief: There are more than 100 different products vying to relieve your pain. Such variety! Such selection! Such a smoke screen! Your choices are basically three: aspirin, acetaminophen, and ibuprofen.

ASPIRIN

It has been called the “prince of panaceas” and “the miracle in your medicine cabinet.” lt’s the little white pill you take for granted and for almost everything else from colds to cramps, from hangovers to headaches, from rheumatoid arthritis to rheumatic fever.
Americans consume more than 80 million aspirin tablets a day, 16,000 tons a year, or roughly 175 tablets per person per year. lt’s one of the earliest painkillers known to man. Two thousand years ago, Hippocrates, the “father of medicine,” told women of ancient Greece to chew the bitter leaves of the willow tree to decrease the pains of labor. Today the active ingredient in those leaves, salicin, has been refined, and now acetylsalicylic acid, or aspirin, is the most popular drug in the world.

Although its chemical structure is simple, we haven’t come close to fully understanding just how aspirin works. Prostaglandins are chemical messengers that are involved, one way or another, in virtually every biological function, but when produced in excess they can trigger pain, fever, inflammation, and more. Apparently, aspirin blocks the manufacture of prostaglandins. Whatever it does, aspirin has enjoyed almost a century of popularity because it works.

Aspirin is the active ingredient in Anacin, Excedrin, and Bayer. Buffered aspirin is also available and promoted as “faster” and “gentler” than plain aspirin. Actual clinical trials, however, have shown no difference in the speed at which plain or buffered aspirin works. As for the claim that buffering protects the stomach, aspirin can indeed attack the stomach lining and cause irritation, especially at the high dosages that are required for an anti-inflammatory effect. But here again researchers studying the claim have found no difference in damage. If a tablet has a special coating that prevents it from dissolving until it reaches the small intestine, then there is protection from stomach upset. Enteric coating, however, is not the same as buffering.

Most people have heard that alcohol and aspirin don’t mix; their combined initating effects may be especially hazardous to one’s gastrointestinal tract. Less well known is the fact that aspirin and vitamin C may have a similar synergistic effect. Vitamin C is ascorbic acid and it is in and of itself a bit of an irritant to the stomach. When combined with aspirin, these two substances may be any thing but healthy. lf you’re taking vitamin C, give the aspirin three hours to clear out of your stomach. And always take any analgesic with a full glass of water or other liquid in order to minimize any stomach upset.

Another side effect of aspirin is of special interest to anyone about to undergo a surgical procedure such as arthroscopy. Aspirin causes platelets, the disc-shaped clotting factors in blood, to become “slippery.” These slippery platelets don’t form clots, which can be beneficial as a protection against stroke but hazardous to
surgical patients, who need their blood to clot in order to halt the bleeding caused by surgery. Thus you should refrain from taking aspirin or other anti-inflammatory agents during the week prior to surgery. If this presents a problem, it should be discussed with your physician.

Aspirin is so commonly used by athletes, I think some people get the idea that aspirin is sports medicine. A few years ago some researchers were actually suggesting that we increase our use of aspirin insports. The theory was that aspirin might prevent cartilage damage by inhibiting certain destructive enzymes. Further study, however, has failed to confirm those initial findings. At the other extreme, some sports medicine specialists are now trying to get aspirin out of the locker room. Many athletes take aspirin to relieve the pain of injuries both big and small and they end up taking ten to twenty tablets a day. One football player who took up to fifteen tablets a day for more than a week ended up with small skin hemorrhages all over his body. This was a result of aspirin’s ability to thin the blood. Does this mean we shouldfget rid of aspirin in
favor of some other pain medication? No. Anything—and especially any drug—taken to excess is bound to be harmful. This argues in favor of medical supervision, not against the use of aspirin.

ACETAMINOPHEN

The most popular aspirin substitute is acetaminophen (Tylenol, Anacin-3, Panadol, Datril), which does not cause as many gastrointestinal problems as aspirin but it also doesn’t offer aspirin’s anti inflammatory effect. Still, it has taken 45 percent of the painkiller market, one percentage point behind aspirin, which had a fifty-five-year head start. That market share, however, is more a testament to advertising success than clinical success. Because of the massive amount of advertising being done, it’s best to remember who’s paying for these ad campaigns. According to Consumer Reports (February 1987), all acetaminophen is created equal. If your brand is more expensive, you’re paying for a massive ad campaign, not for more effective pain relief.

Coming up with powerful descriptors such as “extra-strength” is also a marketing ploy and should not be confused with reality.‘ Most extra-strength pain relievers are just larger doses of the regular-strength drugs. For instance, two extra-strength Tylenol tablets equal three regular-strength tablets. And they offer little, if any, additional pain relief compared to the regular dose. The smallest effective dose of any drug is the dose that should be taken. Such marketing ploys only serve to sell a product and overdose the consumer.

One group of people should avoid acetaminophen—active alcoholics. A Veterans Administration study recently found that acetaminophen can cause serious liver damage in alcoholics, even with moderate doses of the drug. The study leads me to believe that long-term use could even be hazardous to the livers of nonalcoholic patients taking as few as six extra-strength acetominophen tablets a day.

IBUPROFEN

The new kid in town does reduce inflammation as wellas provide pain and fever relief, and apparently accomplishes its task with a stomach-upset profile that is better than aspirin but not quite as good as acetaminophen. Ibuprofen (Advil, Nuprin, Medipren, Ibuprin) has quickly garnered 9 percent of the nonprescription pain-relief market, although it is considerably more expensive than aspirin.

Are you getting anything more for your money? Maybe. Studies suggestthat you may be getting some pain-relief advantages with ibuprofen. Research suggests that one 200-milligram tablet may bring slightly more pain relief than 650 milligrams (two regular strength tablets) of aspirin or acetaminophen. Although ibuprofen manufacturers suggest two tablets should be taken if one doesn’t work, there’s no benefit to taking‘ more than two tablets for normal aches and pains. Studies suggest that dosages above 400 milligrams
don’t increase the level or duration of pain relief except for arthritis, where up to 800 milligrams are used at a time.

For sports medicine use, ibuprofen may hold some slight edge over the competition. Studies suggest it may be better for treating soft-tissue injuries such as sprains and strains. However, as one specialist put it in an overview of these and other non-steroidal anti-flammatory drugs (Sports Medicine, 1986, 32242-46), much of the pertinent world literature on the value and usefulness of these agents in the treatment of sports injuries is “conflictual, vague, and uninstructive."

It’s still too early to tell, but one of the original concerns about ibuprofen was its deleterious effects on the kidneys. Large doses or continued use over time can reduce blood flow to the kidneys, creating a serious situation for people who already suffer kidney impainnent. Those who should take ibuprofen only under a doctor’s supervision include individuals on diuretics or patients with kidney disease, heart disease, severe hypertension, or cirrhosis of the liver. Elderly people, with or without these problems, could also face a risk since kidney function declines with age. Anyone who notices fluid buildup (edema), back pain, increased urination, or a change of color to their urine must contact a doctor immediately. These symptoms could be a sign of kidney damage.