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The Sports Medicine Doctor: No Prescription Required – Treating Musculoskeletal Pain, Part II

By Andrew W. Gottschalk, M.D., Director of Sports Medicine

Champion Orthopedics & Sports Medicine at Cole Memorial Hospital

The day before the 2014 WAs we discussed in the last column, almost all musculoskeletal pain is treated with just two classes of medication. The lone member of Class 1, acetaminophen (brand name Tylenol), is the perfect blend of effective and low risk. Though no medication is completely without risk or side effects, acetaminophen is among the safest pain treatments in modern medicine. The knowledge of the appropriate use of acetaminophen is worth its weight in gold over the course of a lifetime. In the last column, we also began the discussion of Class 2 medications, including ibuprofen (brand names Advil and Motrin). Ibuprofen is the most important medication in Class 2, as it is both effective at treating pain and boasts a safety profile similar to acetaminophen’s.

Let’s continue our discussion of medications in Class 2.

Class 2: Ibuprofen, Naproxen, Aspirin and Others

As I mentioned in the last column, ibuprofen is my favorite Class 2 medication, because it pairs well with acetaminophen when acetaminophen alone is not adequately treating pain.

Naproxen (brand name Aleve) is another Class 2 medication and is similar to ibuprofen. Unlike the easy dosing of ibuprofen (almost always a 200 mg tablet), naproxen tablets come in many different doses. In general, we treat an adult with musculoskeletal pain with about 500 mg (usually two tablets, but check the dose to make sure) twice a day, at breakfast and at bedtime.

Important note: No scientific study has ever shown naproxen (or any other oral Class 2 medication) to be better at treating musculoskeletal pain than ibuprofen. More expensive, yes. More effective at treating pain, no. Drug companies would love for you to overlook this fact, as they would prefer you spend money on their drugs instead.

Aspirin is also a member of Class 2. Aspirin was one of the first pain medications discovered in modern medicine. Found in the bark of willow trees, aspirin was first characterized by a man at Oxford University in England. Aspirin is, without question, as good a pain reliever as ibuprofen. However, an interesting side effect of aspirin is that it “thins the blood” (that is to say blood has a harder time clotting if aspirin is present). Actually, doctors take advantage of this side effect to help prevent strokes and heart attacks in certain populations by placing them on an aspirin a day. But in a younger, healthy individual with musculoskeletal pain, thinning the blood gets in the way of healing. Stick with ibuprofen.

While acetaminophen can be paired with any Class 2 pain reliever, never take more than one Class 2 pain reliever at a time. Each class of pain reliever slows or blocks a different step of the pain pathway in the body. To “team up” on one step of the pain pathway can be dangerous.

In both the last column and this one, we have discussed several pain medications. As always, you should discuss taking any medication with your physician.

If you have been reading closely, you may have noticed that none of these medications require a prescription. One of the most pervasive myths in American medicine is this: If a doctor hasn’t written me a prescription, I am not receiving good care. Nothing could be further from the truth. Good medicine is knowing what works and what doesn’t. Good medicine is knowing whom to ask. The very best medicine is communication and education. The vast majority of musculoskeletal pain can be treated with over-the-counter medications that can be purchased for two dollars or less at the local supermarket.

Furthermore, you don’t need to pay for the names Tylenol, Advil and Motrin. By United States law, the medication in Tylenol is exactly the same as that in a bottle of generic acetaminophen. The same is true of Advil and Motrin; they include the exact same medication found in a bottle of generic ibuprofen. Save the money you would otherwise spend on these brand-name medications, and spend it on a nice “thank you” gift for your mother for having raised you with good common sense.

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