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Like most women who work out regularly, Jennifer Null is no stranger to feeling sore. And like many of the walking wounded, she relies on over-the-counter meds for relief. "When I'm hurting, I'll just pop a couple of ibuprofens," says Jennifer, 28, a marketing coordinator in Baltimore. She does this at least three or four times a week -- a habit that started in college. Jennifer isn't at all worried about the safety of the pills. "They're harmless," she says.
This attitude, shared by many exercisers, could put your health at risk. While over-the-counter pain relievers such as ibuprofen (Advil and Motrin, for example), naproxen (Aleve and others), and acetaminophen (Tylenol and others) have become medicine cabinet fixtures -- used, according to a survey from the National Consumers League (NCL), by 175 million Americans yearly -- the meds are hardly innocuous. When taken incorrectly, as Jennifer and other active women are doing, the little pills can cause real damage.
Modern-day miracle workers for easing the discomfort of strained muscles, stiff joints, swelling, and soreness, OTC painkillers have safely helped countless women stick with their exercise routine instead of seeking refuge on the living room couch. The affordability and accuracy with which these drugs can now address specific pains has changed the way we recover from tough workouts, making it easier than ever to get back on the proverbial horse. And it's tempting to think that if a little pain relief works this well, a lot of pain relief must work even better. Not true.
"Overuse of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, and naproxen, can cause bleeding ulcers, raise blood pressure, damage the esophagus, and lead to problems with the kidneys," says Jan Engle, PharmD, a pharmacist at the University of Illinois College of Pharmacy in Chicago and a past president of the American Pharmacists Association. The NCL reports that 3,200 to 16,500 people die each year from NSAID-related GI bleeding and up to another 107,000 are hospitalized for NSAID-related complications. Although those who suffer from NSAID damage are typically older or have conditions such as kidney problems or ulcers that make them more vulnerable, "young, healthy women who continually use painkillers can also harm themselves," Dr. Engle says.
Acetaminophen can be equally lethal. In fact, overuse of this drug is one of the leading causes of liver failure in the United States, with overdoses resulting in more than 56,000 injuries, 26,000 hospitalizations, and an estimated 458 deaths a year, according to the U.S. Food and Drug Administration (FDA). "More than two-thirds of the cases are women, though we don't know if women are more susceptible or if it's just that they take more medication," says William M. Lee, MD, a liver specialist at the University of Texas Southwestern Medical Center in Dallas and a principal investigator for its Acute Liver Failure Study Group.
And yet, ask for a show of hands of people who've popped three pills instead of two for a bad headache or doubled up on the recommended amount after pulling a muscle at the gym and the pervasiveness of overuse becomes clear. Many people are convinced OTC pain relievers are helpful -- and harmless -- in any quantity. It's so common for consumers to take too much that last year, advisers to the FDA called for significant changes -- including stronger warnings on labels, which have since appeared. They also suggested lower maximum daily dosages for OTC acetaminophen products, but if and how the FDA will proceed is still unknown.
Stronger warnings may not be enough. OTC meds have "become part of the workout ritual," says Stuart Warden, PhD, director of physical therapy research at Indiana University in Indianapolis. Many women training for a sports event will pop a pre-workout pill as a preventive measure. Megan Lewis, 25, is preparing for her second marathon. On days that the college administrator in San Francisco logs 15 miles or more, she takes two 200-milligram tablets of ibuprofen before she hits the road. She believes they protect her from aches and inflammation, although prevention is not actually mentioned on the label. "There's no scientific evidence of prophylactic benefits," Warden says.
Like Jennifer Null, Megan has never talked with a doctor about taking these pills. "People assume that because the meds are over-the-counter, they have to be safe," says Mel Wilcox, MD, a gastroenterologist at the University of Alabama in Birmingham. That nonchalant attitude shows: Only about one person in five reads the directions on an OTC pain reliever label the first time she takes the medicine, and just 30 percent check the dosing instructions, according to a National Consumers League survey. And about one-quarter of people take more than the recommended dosage, a Roper Starch Worldwide survey found.
The risks of such behavior are significant. For starters, using NSAIDs before an activity can mask pain, causing you to unknowingly worsen an injury. Plus, NSAIDs such as ibuprofen block the action of enzymes that repair and strengthen tissue, so extended use can actually delay the healing of injuries like muscle and tendon tears. "Prolonged use of NSAIDs by athletes is simply not safe or effective," Warden says.
Ibuprofen eases pain by interfering with the body's production of prostaglandins, substances involved in inflammation. Normally, blocking prostaglandins isn't a problem. But because they cause blood vessels to dilate, which, in turn, increases blood flow to the kidneys, decreasing prostaglandins' effectiveness can slow kidney function. At the same time, strenuous exercise makes the body release proteins called myoglobins, which help build muscle but also weaken the kidneys. Without prostaglandins to increase blood flow, the kidneys may shut down.
Potential OTC pain reliever dangers were highlighted by a 2006 study of ultramarathoners competing in a 100-mile race through the Sierra Nevada. Seven in 10 participants took ibuprofen before or during the race. Runners taking the maximum daily dosage (six 200-milligram tablets) had a 50 percent higher rate of inflammation than those who didn't, and they also suffered from weakened kidney function, researchers found. "Not only was the ibuprofen ineffective, but it had the opposite of the desired effect," says lead study author David Nieman, DrPH, an exercise physiologist and the director of the Human Performance Laboratory at the North Carolina Research Campus in Boone. "Essentially, it promoted inflammation and impaired kidney function."
Despite these concerns, OTC pain meds can still be a valuable tool for exercise recovery, provided you use them as directed. Which one you should choose depends on your symptoms. In most cases, the safest option for simple relief (sore hamstrings, for example) is acetaminophen because it has the fewest side effects, says Robert Sallis, MD, codirector of the Sports Medicine Fellowship at Kaiser Permanente Medical Center in Fontana, California. (Avoid drinking while you're taking it, since alcohol increases the drug's toxicity.) For temporary relief of swelling, redness, and joint-related inflammation (due to, say, a minor sprain), go with an NSAID (ibuprofen or naproxen).
If your aches are chronic, you should consult a doctor. But until then, consider cutting your OTC dose in half, knowing that you may take the meds more often than someone with a one-off injury. "I take half a dose of Aleve before I go to bed if I feel any pain," says Jennifer Mounce, a 39-year-old San Francisco-based executive coach who works out at least five times a week. Her enthusiasm for Spinning classes, yoga, and free weights frequently leaves her achy, so she checked with her doctor about the right course of treatment. "Although it is OTC, it's still a pretty powerful drug, and I take it frequently -- maybe two to three times a week," she says. "I wanted to be sure it was safe."
Even if you take a reduced dose, cross-check the label with those of any other meds you may be taking. Over-the-counter remedies for colds, flus, coughs, and other everyday ailments frequently contain acetaminophen or ibuprofen already. "About 50 percent of the overdoses are inadvertent," Dr. Lee says. "People take pills for pain and then add in other medications such as NyQuil or Tylenol PM to go to sleep."
Some experts, though not all, feel that acetaminophen and ibuprofen can be used in combination without causing any serious adverse side effects because they take different pathways of action. But if you require several meds to keep pain in check, it could be a warning sign that you're overdoing it on exercise or have damaged tissue, Dr. Engle says. Rather than taking pills every few hours, talk with your physician.
Also, although the maximum FDA-recommended daily intake of acetaminophen is 4,000 milligrams (the equivalent of eight 500 milligram extra-strength pills taken two at a time over 24 hours), "athletes should limit their daily intake to no more than 2,000 milligrams," Dr. Sallis says. "It's a conservative dose, but it makes sense because of the added stress the liver and other organs already undergo during vigorous exercise."
Ultimately the best remedy to take to recover from a tough workout may not come in a bottle at all. Icing muscles at least 15 minutes immediately following intense exercise may ease inflammation and minimize pain more effectively than medicine. Massage, hot baths, and gentle walking or jogging (known as active recovery) the following day can help as well. "For people who've been exercising heavily, nonpharmaceutical methods are more beneficial than anything else," Warden says.
After years of dealing with the aches that came from pursuing her fitness passion, Meredith Castelli finally realized the best way to treat her exercise-induced pain was...with more exercise. The 38-year-old fitness instructor from Gainesville, Virginia, hits the gym five times a week, lifting weights and working up a sweat on the treadmill or elliptical machine. "I take OTC pain meds only as a last resort," Meredith says. "If I get sore, I'll walk the next day and do a lot of stretching, which boosts blood flow to aching muscles. Over the years, I've found it's the fastest way to recover and get back in the game."
These supplements can relieve inflammation and soreness, according to Mark Moyad, MD, MPH, a FITNESS advisory board member and the director of Preventive and Alternative Medicine at the University of Michigan Medical Center in Ann Arbor.Try This: Glucosamine
A naturally occurring compound that helps prevent joint degeneration. Studies show that it eases inflammation and joint swelling and reduces pain as effectively as ibuprofen. The recommended dosage is 1,500 milligrams a day. Choose glucosamine sulfate over glucosamine hydrochloride; it's easier for your body to absorb.Try This: S-adenosylmethionine (SAM-e)
A substance produced in the liver that maintains cartilage thickness and eases inflammation. A head-to-head test of SAM-e (1,200 milligrams a day) and the prescription NSAID Celebrex (200 milligrams a day) found that after two months, pain relief was the same with both. The suggested dosage is 200 milligrams three times a day; the butanedisulfonate salt form is preferred.Try This: Omega-3 fatty acids
A one-two punch of omega-3s, found in fish oil, and glucosamine sulfate may be as effective as prescription meds. A 2009 study of patients with severe arthritis in the hip or knee revealed that combining glucosamine sulfate (1,500 milligrams) with omega-3 fatty acid supplements (200 milligrams) reduced pain and joint stiffness by more than 50 percent. The suggested daily intake is three to five grams.
Originally published in FITNESS magazine, May 2010.