Ibuprofen and Acetaminophen vs. Opioid Therapy for Acute and Chronic Pain

Acetaminophen, ibuprofen and opioids are all effective in relieving pain. Non- prescription pain medications are commonly used in the US, with sales of 4.3 billion in 2018. Sales of opiate medications were 200 billion dollars in 2016. Because the efficacy of acetaminophen, ibuprofen, and opioids are well supported, the medication of choice often depends upon patient and physician preference.

Opioid medications refers to a group of pain medications that includes morphine, oxycodone and hydrocodone among others. They bind to receptors in the central nervous system that normally bind endogenous opioids such as endorphins. The effect of opioid binding depends on the location of the receptors; for example, in the nucleus accumbens, opiate receptor activation decreases the release of inhibitory neurotransmitters, which ultimately leads to increased dopamine release. Opioids were liberaly prescribed for a variety of acute and chronic pain conditions in the 1990s to 2010s. As more data has emerged about the potential for addiction to opioid medications, regulatory policies at the federal and state levels have tried to pressure providers to prescribe these medications with less frequency.

Ibuprofen is a member of a class of medications called non-steroidal anti-inflammatories (NSAIDs), which includes naproxen and diclofenac. These medications work by decreasing the production of prostaglandins, which are lipids derived from arachidonic acid and produced in every cell (especially epithelial cells of blood vessels). Prostaglandins act as vasodilators and provide a signal that localizes white blood cells to the site of tissue damage, contributing to the body’s inflammatory response. Acetaminophen is thought to work through effects on multiple pain pathways, including prostaglandin synthesis and the serotonergic, opioid and nitric oxide pathways. The exact mechanism by which acetaminophen works to decrease pain is not fully understood.

Pain medications – especially opioid pain medications – are often used in the immediate postoperative period. Some clinical data suggests a combination of acetaminophen and ibuprofen provides more pain relief after surgery than either opioids alone or a combination of opioids and acetaminophen. Opiate medications are also commonly used to treat pain from traumatic injuries. For these cases, there is a lack of research with which to compare the efficacy of opioids, acetaminophen and ibuprofen in providing pain relief. However, in clinical practice a combination of opioids and acetaminophen is often used, while ibuprofen is less commonly used because it may impair bone healing after trauma or surgery. 

Acute low back pain is also often treated with pain medications. For this type of acute pain, non-opioid medications including acetaminophen and ibuprofen may possibly be more effective than opioid treatment. In fact, one study found that people who started taking opioid medications after acute low back pain were more likely to have surgery and more likely to still be on opioid medications four years later. 

Acetaminophen, ibuprofen and opioids are all used in the treatment of chronic pain, and all can have adverse effects which are more likely to occur with prolonged use. Long term use of opioids is more likely to lead to dependence and can cause increased perception of pain. Notwithstanding, long term use is typically recommended for pain due to cancer or other terminal conditions. However, there is a lack of significant data to support the use of opioids for chronic pain. Acetaminophen and ibuprofen are both effective at chronic pain relief but have potential adverse effects which should be taken into consideration. Acetaminophen may cause liver damage when used in high doses over long periods of time, and chronic use of ibuprofen can be harmful to the heart, kidneys, and stomach. The use of any of these medications should be discussed with a physician prior to long term use.  

References:

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Teater, D. Evidence for the efficacy of pain medications. National Safety Council White Paper. Oct 2014. 

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