Tylenol

EVERY DAY, millions of Americans fumble through their medicine chests, searching for pills to make the hurt go away. While there are dozens of pain relievers available over the counter or by prescription, recent revelations served as a reminder that these valuable medications must not be taken too casually. Vioxx, a prescription arthritis drug, was voluntarily withdrawn from the market when a study found that it increased the risk of heart attacks and strokes. Two similar medications, Celebrex and Bextra, subsequently came under heightened scrutiny, with some study results showing that persistent use at high doses has small but significant circulatory risks. Complicating the situation was a study by the National Institute of Aging that vindicated Celebrex, yet indicated that naproxen, the popular over-the-counter drug known as Aleve, might boost the chance of heart attacks. But that result contradicts earlier investigations finding no risk and even some heart-protective benefit with naproxen.

Consumers were caught off guard, but the news was less surprising to doctors who treat chronic aches. "Those of us who are in the pain-medicine trenches know that there are adverse reactions and side effects to all of the medications we choose to try on our patients," says James Dillard, M.D., clinical director of Columbia University's Rosenthal Center for Complementary and Alternative Medicine, and author of The Chronic Pain Solution.

Dillard prescribes reason: People should "take a deep breath" and recognize that the scary headlines stem from long-term use of drugs that can be taken safely for short periods, he says. However, he adds, "these revelations have intensified the interest that I think people should have in nonpharmacological approaches to pain."

fast, fast relief

A GROWING NUMBER of doctors believe that in some cases, herbs, supplements, and other natural remedies can augment or even replace prescription and OTC pain relievers. But don't toss the Advil, Tylenol, or Bufferin just yet. These products--which contain ibuprofen, acetaminophen, and aspirin, respectively--tend to work faster than natural medicines, a difference that can be significant when you suffer an acute injury.

"If you need immediate relief, herbal medicine often doesn't do that," says Joel J. Gagnier, N.D., a naturopathic doctor and clinical epidemiologist at the University of Toronto. So when you get bonked on the head playing volleyball, "ibuprofen is fantastic," Gagnier says. "But it's not the kind of thing you want to take chronically."

Here's why: Ibuprofen, like aspirin, naproxen (Aleve), and ketoprofen (Orudis KT), belongs to the category known as non-steroidal anti-inflammatory drugs. While these pills quell pain effectively, taking them for an extended period can cause stomach problems. In fact, NSAIDs annually send about 100,000 people to the hospital with ulcers and other gastrointestinal disorders. To avoid tummy trouble, many people use Tylenol or other brands of acetaminophen. But they often don't know when to stop--overdoses of acetaminophen are responsible for nearly half of all cases of acute liver failure.

Natural pain relievers can have side effects, too, Dillard notes, and may interact with commonly used drugs. But while they generally take longer to act, they may provide a gentler path to pain relief. If you decide to ask your physician about restocking your medicine chest, here are some alternatives that could help control the most common types of distress.

headaches

THE COMMON TENSION headache is the No. 1 reason Americans use over-the-counter analgesics. While acetaminophen and NSAIDs are fine for treating occasional pain on the brain, too-frequent use of these medicines can cause headaches; such reactions are called "rebound headaches."

Some physicians believe that chronic headaches may actually be related to migraines. The most effective treatments for a migraine in progress are drugs called triptans, such as Imitrex, says Alexander Mauskop, M.D., director of the New York Headache Center in Manhattan. However, Mauskop believes that prevention is the best strategy. Half of all migraine sufferers have low levels of magnesium, he notes, which may cause chemical changes in the brain that lead to migraines. "Giving magnesium supplements to patients who are deficient often produces dramatic improvements," says Mauskop, who recommends 600 milligrams per day.

Additionally, five controlled investigations have shown that migraineurs who take the herb feverfew suffer fewer attacks, says Mauskop. A nutritional supplement called MigreLief contains a combination of magnesium, feverfew, and another reputed headache buster, riboflavin (aka vitamin [B.sub.2]).

back pain

OVER 30 MILLION Americans woke up with a sore back today. Many of them will pop an aspirin or Advil. But the risk of stomach backlash can make that strategy too much of a gamble, says Jacob Teitelbaum, M.D., author of Pain Free 1-2-3. "By the time you get an effective dose, you get a lot of side effects," he notes.

Instead of aspirin, Teitelbaum prefers a closely linked natural alternative. Willow bark extract contains salicin, which is chemically related to the active ingredient in aspirin. Although willow bark, too, can cause stomach problems, they are relatively uncommon. In one report, published in Rheumatology, taking 240 mg a day of willow bark extract for four weeks relieved back pain just as effectively as Vioxx.

Another botanical candidate is devil's claw. "The research is strong for relief of low-back pain," says Gagnier, who analyzed a number of studies done on devil's claw for the journal Complementary and Alternative Medicine. Gagnier advises taking 2,000 to 2,500 mg daily of devil's claw divided into three doses (or enough to get 50 to 100 mg of harpagosides--check the product label to be sure).

joint pain

GLUCOSAMINE and chondroitin are often recommended for osteoarthritis pain and stiffness, which is caused by loss of cartilage in the joint. A dozen studies have shown that these supplements reduce symptoms of osteoarthritis by about 40 percent, on average. The usual dose of glucosamine (derived from crustacean shells) is 1,500 mg per day. The standard dose for chondroitin (made from animal cartilage) is 1,200 mg, though it can be poorly absorbed and may require higher doses.

Other studies show that pain and swelling caused by rheumatoid arthritis (a condition that occurs when the body's immune system mistakenly attacks the joints) respond well to fish oil. Teitelbaum recommends 1 to 2 tablespoons of liquid fish oil per day. Adding evening primrose oil, a source of gamma-linolenic acid, may enhance pain relief, he says.

Another option is SAMe (short for S-adenosymethionine), a compound produced naturally in the body that may help reduce pain and inflammation, and increase the production of molecules that support bone and cartilage. One recent study, published in Musculoskeletal Disorders, compared SAMe with Celebrex. "We found that [a 1,200 mg daily dose of] SAMe was, in general, as effective as Celebrex in controlling pain and improving function," says lead author Wadie Najm, M.D., of the University of California, Irvine, Medical Center. One important caveat about SAMe: It may take a month or so before you feel any relief.

Or consider turning up the heat. Capsaicin cream, derived from hot peppers, may sting and itch the first time you apply it to the skin. But with repeated applications, nerve endings are depleted of a chemical that transmits pain signals to the central nervous system. "It fools the brain," says Dean Neary, N.D., chair of physical medicine in the school of naturopathic medicine at Bastyr University, near Seattle. A study in the European Journal of Pain found that subjects who applied .025 percent capsaicin cream to arthritic joints for six weeks experienced a significant reduction in pain.

muscle aches

DO YOU gobble pain relievers after Spinning class? An antioxidant defense may reduce your post-workout misery. "There's something preventive in high vitamin C usage," says Declan Connolly, Ph.D., associate professor of exercise physiology and director of the Human Performance Laboratory at the University of Vermont. Connolly, who cites studies suggesting vitamin C can help reduce exercise-related muscle damage, advises serious athletes to take 1,000 mg daily and people who work out regularly to take at least a daily multivitamin.

Bromelain might also soothe the pain, says Neary. Bromelain pills contain pineapple enzymes, which appear to have anti-inflammatory and analgesic properties. Previously shown to reduce arthritis symptoms, bromelain may be effective in "ameliorating physical symptoms and improving general well-being in otherwise healthy adults suffering from mild knee pain," concludes a study in Phytomedicine.

Kept up at night by leg cramps? Consider mineral therapy. Like migraines, frequent muscle cramps could be caused by a calcium and/or magnesium deficiency, says Neary. Supplementing might ward off spasms; ask your doctor about dosage, but don't exceed 1,500 mg of calcium and 750 mg of magnesium daily.

Successful--and safer--pain management requires a proactive patient. So talk to your doctor about your symptoms in order to find the best combination of prescription, over-the-counter, and natural responses, and stay within the recommended dosage. Finally, don't forget to think outside the medicine cabinet: A regular workout and proper diet can help keep your body strong and pain-resistant.

TO TAKE OR NOT TO TAKE

Persistent pain plagues nearly one out of six Americans, which means there are times when we need the power of pharmaceuticals. Here are the pluses and minuses of the most common OTC and prescription pain relievers.

Aspirin

Brand names: Bayer, Bufferin, Ecotrin Advantage: Reduces inflammation. Disadvantage: May harm the stomach.

Ibuprofen

Brand names: Advil, Motrin, Nuprin

Advantage: Reduces inflammation; may be more potent than aspirin.

Disadvantage: May harm the stomach.

Naproxen

Brand name: Aleve

Advantage: Reduces inflammation; may provide longer relief than ibuprofen.

Disadvantage: May harm the stomach; effect on the heart uncertain.

Ketoprofen

Brand names: Orudis KT, Actron

Advantage: Reduces inflammation.

Disadvantage: May harm the stomach.

Acetaminophen

Brand names: Tylenol, Aspirin-Free Anacin

Advantage: Doesn't harm the stomach.

Disadvantage: Doesn't reduce inflammation; heavy use may harm the liver (especially when combined with alcohol).

Cox-2 Inhibitors

Brand names: Vioxx (withdrawn), Celebrex, Bextra

Advantage: Reduce inflammation; may be less damaging to stomach than other NSAIDs.

Disadvantage: Prescription needed; may pose heart risks.

PILL-FREE PAIN RELIEF

There is plenty you can do for yourself before you go running to the medicine chest, says James Dillard, M.D., author of The Chronic Pain Solution. Here are a few ideas:

Try some RICE. As in "rest, ice, compression, and elevation." For nasty bumps and bruises, there is no better therapy than taking it easy and applying a cold pack to the injured part of the body for 20 minutes to ease the pain. Then, if possible, wrap the area in a snug-butnot-tight elastic bandage and elevate to control swelling.

Play it cool (or take it hot). Physical and emotional stress can cause or worsen pain. Try meditation, yoga, or a hot shower to relax.

Find a friend in knead. Easing muscle tension sometimes takes hands-on effort. No need to pay for a massage; enlist a family member to work on your back and shoulders, and then return the favor.

Work your body. Well-trained muscles are less likely to become sore after a workout. (You can usually distinguish injury- or illness-related pain from delayed-onset muscle soreness, which may occur temporarily about 24 to 48 hours after working out with weights, and is a normal side effect of building muscle.) If you're exercising through the soreness, your muscles will be weaker and the workout less comfortable. You can still burn a few calories; just lower your expectations.

Seek the source. lf you're in need of pain pills every day, you're only treating the symptoms. "Treat the cause," says Dean Neary, N.D. "Poor posture at work, for example, can cause problems." Make sure your desk chair supports your body properly, and check spine-health.com for other ways to make your workplace more body-friendly.

Illustration by TRACY WALKER

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