The Family Health Guide

Yellow light on pain relievers

The abrupt announcement by drug maker Merck in the fall of 2004 that Vioxx was linked to an increase in heart attack risk triggered a closer look at all of the medications we reach for to ease pain, calm inflammation, and cool fevers.

Under the magnifying glass, every pain reliever — indeed, every drug — has its flaws. To help doctors and the rest of us make the safest painkiller choices, the American Heart Association (AHA) has come out with step-by-step recommendations. Aspirin and acetaminophen top the AHA's list of preferred options. The AHA experts list narcotic pain relievers next as a possibility for short-term problems. Then come naproxen and other anti-inflammatory drugs, followed — as a last resort — by the COX-2 inhibitors, of which Celebrex is the only member.

The AHA dissects the differences and offers a pain relief strategy that starts with the least risky medications and works its way down to riskier ones if needed.

Safe start

The safest option for quelling muscle or joint pain is a nondrug approach. Try heating pads, ice, and physical therapy first. Even if they don't completely do the trick, they may at least let you cut back on how often you take a pain reliever or how much you take.

For most people, the first pain reliever to start with is aspirin or acetaminophen. Their advantages? Aspirin is good for the heart, and acetaminophen kills pain in a different way than NSAIDs, so it doesn't affect blood clotting like they do. Both drugs have side effects, of course. Aspirin can upset the stomach and cause bleeding in the digestive system. Acetaminophen can damage the liver, especially at high doses or when it is in the body along with alcohol. Four grams a day (12 regular-strength Tylenol tablets) is considered a safe upper limit, but that might be too much for people whose livers aren't in tip-top shape or who drink daily.

If aspirin or acetaminophen doesn't work for you, the AHA suggests a narcotic pain reliever as the next step. These include prescription drugs such as tramadol (Ultram), codeine, and fentanyl (Actiq, Duragesic). While narcotics probably aren't the right choice for arthritis pain, they might be an option for short-term aches like a severe muscle strain.

Climbing higher

If those options don't work, the next step is another NSAID. Try naproxen (Aleve) first. After that comes ibuprofen (Advil); next is diclofenac, but more caution is needed with it since it blocks COX-2 more than COX-1.

Caution with COX-2 inhibitors

Celebrex, the only remaining COX-2 inhibitor on the market, should be the last resort for managing pain. These drugs ease pain and inflammation and may be a bit easier on the stomach than other NSAIDs. But in addition to their side effect of increasing the risk of clots in the bloodstream, COX-2 inhibitors can also reduce blood flow through the kidneys, cause them to hang onto sodium, and increase blood pressure.

If Celebrex is the only painkiller that lets you get through the day, then use it. But do so with your eyes wide open to the possible hazards. Make sure you know the warning signs of a heart attack or stroke, and have your blood pressure and kidney function checked every six months or so.

Using common sense

Don't be afraid to take aspirin, Tylenol, Advil, or Aleve for a headache or other occasional aches and pains. If you need one several times a week, that's when you need to pay more careful attention. Stay in touch with your doctor, and remember to mention any over-the-counter medications, especially pain relievers, that you are taking.

July 2007 update