In this installment of “Dear Julia,” Vox health reporter Julia Belluz takes on a reader question about pain medications. The reader wants to know which over-the-counter (OTC) pain reliever is the best for treating pain – Tylenol, Advil or aspirin. The story presents evidence from high-quality studies and opinions from three pain experts. The story carefully explains that it’s not appropriate to state unequivocally that one beats the other because it’s not a one-size-fits all situation. In general, though, ibuprofen (name brand Advil) is more effective and safer than acetaminophen (Tylenol) and aspirin in beating minor pain.
The “Dear Julia” column, which debuted earlier this month, promises to answer “everyday health questions on anything from the science of hangovers to the mysteries of back pain.” The column is off to an auspicious start, and we look forward to more of its practical, evidence-based responses. You can submit a question for the column here.
Americans spent $4.4 billion on OTC analgesics in 2014, according to the Consumer Healthcare Products Association. Despite wide use and efforts by public health efforts to inform consumers about safety issues, there’s still a lot of confusion about which medication works best for different ailments. As the article points out, acetaminophen is the most popular selling OTC pain reliever but not always the most effective or safest.
The story doesn’t mention costs but since these over-the-counter medications have been widely available for a long time it doesn’t seem like an important omission. Because aspirin has been available the longest and is manufactured by literally hundreds of companies, it is by far the cheaper of the three.
The article takes a close look at the drawbacks and benefits of each drug. For example, while the experts said acetaminophen is less effective than ibuprofen in treating pain (and carries more risks than the others), it is beneficial in treating fever, especially in children age three and up. Ibuprofen is deemed less toxic for pain relief but it carries the risk of bleeding in the gastrointestinal tract and kidney damage. There’s also a reasonable amount of quantification provided by an expert source, Dr. Andrew Moore, who says: “If you’re talking about aspirin in doses of 500 to 1,000 mg or two tablets, 30 percent of people get relief from acute pain. For acetaminophen at doses of 500 to 1,000 mg, about 40 percent have a success. For ibuprofen, in its normal formulation at something around 400 mg or two tablets, about 50 percent have success.” The story would have been even stronger had it provided links or additional details regarding where this expert obtained his estimates.
The story comprehensively describes the harms from each drug based on different uses and patient populations. We especially liked this quote: “Don’t believe that just because something is over-the-counter, it’s safe.”
The story cites and links to reliable evidence sources, including a systematic review of randomized controlled trials on back pain published in the BMJ.
There are no examples of disease mongering in the story.
Sourcing is a very strong component of the article. The story quotes three pain experts from three different institutions as sources. No conflicts of interest were apparent.
The main premise of the story was comparing which pain medication was the best for different types of pain. The comparisons are covered in depth with perspectives from three sources.
It’s obvious from the story that all of the medications profiled have been widely available without a prescription for many decades. Aspirin, a modified version of salicyclic acid, was created by a Bayer chemist in 1897; acetaminophen followed in 1956; and ibuprofen in 1962.
The story establishes that it’s responding to a reader question about three well-known and widely used medications. It also notes the gap between public perception about these drugs and what pain researchers think of them.
Since this article was prompted by a reader question and includes comments from three expert sources, we are confident it isn’t based on a news release.
Systematic, Criteria-Driven
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Comments (2)
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Mark Schoene
August 31, 2015 at 8:44 amDon’t think the VOX article deserves such a high score. It contains some factual errors. And the message that ibuprofen is the “go-to” drug for treating minor pain is certainly open to question (at least in the back pain area)—and conflicts with the recommendations in many evidence-based guidelines.
The article mischaracterized the BMJ review (Machado, 2015) it used as one of its evidence anchors. “A 2015 systematic review of high-quality evidence, published in the BMJ, found that acetaminophen didn’t seem to help most sufferers of chronic low back pain, and that it barely alleviates pain in people with osteoarthritis.”, according to the VOX article.
The evidence on acetaminophen for back pain in that review pertains only to acute back pain (coming largely from a single RCT), not chronic. The only RCT to ever look at acetaminophen for chronic back pain (Wetzel, 2014) was included in that review—but has been retracted. (http://www.ncbi.nlm.nih.gov/pubmed/25747315).
The vast majority of international guidelines on low back pain don’t recommend NSAIDs, or ibuprofen in particular, as the analgesic(s) of first choice for low back pain. Most recommend acetaminophen because of its safety profile. (Koes, Eur Spine J. 2010 Dec; 19(12): 2075–2094.)
The 2007 American College of Physicians/American Pain Society review (Chou, Annals of Int Med, 2007) on medications for low back pain offered what might be the best conclusion about choice of analgesics for pain: “Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.”
Mark Schoene
Editor, BackLetter
Consumer Representative, Cochrane Back and Neck
Julia Belluz
September 2, 2015 at 8:08 amMark, thank you for your comments. Yes, that the BMJ review mainly looked at evidence for acute low back pain, but the evidence on these drugs for chronic pain is limited and some of the guidelines you cite are out of date and not reflective of the latest research. I ran your comments by the researchers I spoke to as well as Roger Chou (who you cite here) and they agreed the conclusions I drew were correct based on the latest research — that ibuprofen appears to be more effective. Still, I have added some notes in the piece that should clarify that limitation on the BMJ study. In any case, thank you for taking the time to comment and feel free to email me if you have any further remarks.
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