Best and Worst Pain Relievers

Now doctors have solid medical evidence about the best treatments for acute pain, the kind that is triggered by tissue damage and inflammation from surgery, dental work or an injury. A new Cochrane Review pooling data from about 45,000 patients involved in approximately 350 separate studies evaluates the effect you can expect from taking commonly used painkillers at specific doses, and also identifies drugs that aren’t likely to help. The review, published this month, will help doctors make better choices to improve patients’ comfort and aid recovery after painful medical procedures.

“Pain relief doesn’t have to be a mystery,” said lead study author Dr. Andrew Moore, of the Oxford Pain Research Unit at Oxford University in the UK. An important finding was that no drug gave all patients a high level of pain relief, but the most effective medications helped more than 70 percent of patients, while the worst only gave 14 percent significant relief. The review also found that the time period over which pain was quelled varied from about 2 hours to 20 hours. Here’s a closer look at the findings.

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What kind of pain was studied? The review looked at randomized double-blinded clinical trials of the effects of various pain relievers on adults suffering moderate to severe pain after any type of surgery, including wisdom tooth removal and other dental procedures, abdominal operations, surgery on joints or bones, and episiotomy (a surgical incision performed during vaginal childbirth). The review analyzed 35 previous Cochrane reviews of randomized studies comparing how well various pain relievers worked against post-surgical pain.

Which drugs were evaluated? The review looked at 3 categories of pills that are commonly used to relieve acute pain:

1.  Mild or “step 1” non-steroidal anti-inflammatory drugs (NSAIDS). This category of drugs includes over-the-counter medications such as:

  • aspirin (Bayer Bufferin, Excedrin)
  • ibuprofen (Advil, Motrrim, Nuprin)
  • naproxene sodium (Aleve, Anaprox)
  • acetominophen (Tylenol, Tempra, and Paramol)

This category also includes prescription NSAIDs such as:

  • celecoxib (Celebrex)
  • etoricoxib (Arcoxia)
  • aceclofenac (Hifenac)

2.  Moderate” or “step 2” painkillers, including weaker narcotic drugs like codeine.

3.  Strong or “step 3” painkillers, which are powerful narcotic opioids, such as:

  • oxycodone (Dazidox, ETH-Oxydose, Endocodone, Oxycontin, Percolone)
  • fentanyl (Actique, Durogesic, Fentora, Onsolis).

How do these drugs work? NSAIDs temporarily blocks enzymes called COX-1 and COX-2 that regulate production of prostaglandins, substances that play a key role in inflammation and pain. Aspirin blocks COX-1. Unlike NSAIDs, paracetamol (acetominophen) doesn’t combat inflammation and its method of pain relief isn’t fully understood. The opioids in narcotic painkillers bind to receptors in the central nervous systems, reducing pain signals, but also can cause such side effects as drowsiness, nausea, vomiting, and constipation. To reduce these problems, opioids are often combined with non-opioids.

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What are the best painkillers? More than 70 percent of patients with moderate or severe post-procedural pain achieved a high level of pain relief after receiving:

  • 120 mg of the prescription drug etoricoxib (Arcoxia)


  • a combination of 2 OTC drugs: 500 mg of paracetamol (acetominophen, Tylenol, Tempra, and Paramol) plus 200 mg of ibuprofen (Advil, Motrrim, Nuprin)

With other drugs, including 1,000 mg of aspirin and 600 mg of paracetamol taken on their own, only 35 percent of patients benefitted. The review found that 46 drug/doses were at least somewhat effective.

What are the worst pain relievers? Patients who received the following pain relievers after surgery didn’t get any more pain relief than patients who were given a placebo (lookalike fake pill):

  • 500 mg of aspirin (Bayer Bufferin, Excedrin)
  • 150 mg of aceclofenac (Hifenac)
  • 5 mg of oxycodone (Dazidox, ETH-Oxydose, Endocodone, Oxycontin, Percolone) 

The review found that only 14 percent of patients with moderate or severe post-operative pain benefitted from taking codeine, the lowest amount of benefit from the drugs that did work. And there was insufficient evidence to tell if the dexibuprofen (Anyfen, Dexpro, Seractil, Dexprofen) in doses of 200 or 400 mg, 130 mg of dextropropoxyphene (Darvon, Darvocet), 125 mg of diflunisal (Dolobid), 60 mg of etoricoxib (Arcoxia), 400 or 800 mg of fenbufen (Lederfen, Fenbuzip), or 50 mg indometacin (Indocin) are helpful with post-surgical pain or not, the review reported.

How can I make sure to get the best pain reliever after surgery or dental procedures? Discuss which pain reliever the surgeon plans to prescribe as well its pros and cons, the potential side effects, and why the MD considers it the best drug for you. If you have trouble swallowing pills or experience gastrointestinal side effects from NSAIDs, also talk to the doctor about the possibility of using a pain patch. Be sure to alert the doctor to any drug allergies or adverse reactions you’ve experienced in the past and discuss non-drug methods to treat your pain, such as ice packs. And if the first medication the doctor tries isn’t helpful, the Cochrane Review will help the MD find other effective options, based on high level of medical evidence.

Pain Patches Offer an Alternative to Pills.


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