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Comment by dajohnson89 | Hacker News Reader

Agreed that opiods are overprescribed, but for acute pain there's no comparison. At least in my experience.

I was rushed to the ER with an excruciating condition, and i popped quite a bit of ibuprofen at home before going to the hospital (i think 4-6?). Nothing.

In the triage room or whatever, that morphine drip (plus saline IV to replace all fluid i vomited up due to pain) made the 8/10 pain reduce to a 2-3/10, allowing me to bear with it until i was put under general anesthesia for surgery.

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>In a randomized, double-blind clinical trial—the gold standard of trials—a combination of ibuprofen (Advil) and acetaminophen (Tylenol) was just as effective at treating patients with acute pain in an extremity as three other pain-killer combinations containing opioids.

They tested medicine combinations (400mg of ibuprofen and 1,000mg of acetaminophen), not ibuprofen alone.

Extremity pain (arms and legs) was tested only, not pain in general.

They only tested medications delivered orally, not intravenously. That distinction is very, very important as intravenously administered medications have a much higher placebo effect than orally administered medications. In fact, I'd love to see a comparison of orally administered opioids vs intravenously administered NSAIDs.

They didn’t say opioids are no better than either acetaminophen or ibuprofen; they said that opioids are no better than the combination of ibuprofen with acetaminophen — something very rarely prescribed (and usually advised against on the labels of both drugs.)

counter-anecdote: my doctor told me to use precisely that combination for severe pain. She said you cannot combine multiple NSAID's (ibuprofen, naproxen, ASA), but you can combine an NSAID with acetaminophen.

Same. In the hospital I was given small doses of morphine, and frankly I was shocked at how well it worked. I've had demerol for kidney stones, and it didn't do much for pain.

But the morphine at the hospital was like magic. And the dose low enough I didn't really feel any other effects.

That said, when it was time for discharge, the doc told me to alternate tylenol and advil every 2 hours (4 hour cycles each), as needed.

It wasn't news to me. I've followed the protocol before. I wasn't really in much pain by the time I was discharged, so I didn't bother with it this time and can't really compare.

Agreed; I've been prescribed that combination more than once by different doctors. It's very common, and often the recommendation is to stagger them. NSAIDs are metabolized by the kidneys and acetaminophen is metabolized by the liver, so they can be safely combined.

EDIT: also, this is pretty much what Excedrin is (aspirin instead of ibuprofen, but NSAID + acetaminophen, plus also caffeine)

As a migrainer, excedrin really only works part of the time. Though, opioids really only succeed in making me not care about the pain. I’m still in pain with them.

The best treatments, for me, directly address whatever underlying issue.

Drifting off-topic, but have you tried sumatriptan ("Imitrex")? It seems to have a near-total effectiveness on my ~monthly migraines. Neither acetaminophen nor NSAIDs ever did anything for my migraines.

I agree that directly addressing underlying causes like stress, noise, sleep, and diet are better than a pill.

I was about to say the same thing - sumatriptan works amazingly well for my migraines. I'm in the UK though, and I seem to recall someone on HN saying it was very expensive in the US.

It might have once been expensive ("Imitrex" (R)(TM)) but there is a generic now. I understand there are also non-pill delivery systems, like nasal or patches, and other permutations that may still be under patent. The pills seem to work for me.

Triptans work for me as well, but they’re too hard on my body. It’s aftually pretty scary how they work.

Can I ask what side effects it is you get? Just curious since there don't appear to be any negative effects at all for me.

It works by causing your muscles tissues to dialate or something like that. My doctor explained taking too many in too short a time could cause a stroke or heart attack, forget which exactly. One side effect i get is my skin becoming highly sensitive to heat. We’re talking luke warm shower water feeling something like scalding hot. It’s not that exactly either, very weird sensation. Other times my throats tensed up similar to when you eat something highly sour.

We do this pretty often for the patients that come into our student run clinic. We aren't allowed to prescribe opioids, so we tell them to alternate ibuprofen and acetaminophen every 4 hours. Works pretty well, and doesn't stress your liver or stomach as hard.

I take that for every tension headache (which isn't often, I mostly get migraines and clusters): 3 ibuprofen and 2 tylenol.

I had no idea the labels said otherwise.

I believe the study, but I've also taken opioids for pain and for me personally there's no comparison. Not even close. Placebo?

NSAIDS + acetaminophen are very common. Excedrin is acetaminophen + aspirin (and caffeine).

>and usually advised against on the labels of both drugs.

I've never seen this.

Acetaminophen and ibuprofen are safe and effective together.

The label you refer to advises against using other medicines that contain acetaminophen, as many cold and allergy medicines do (Excedrin, NyQuil, Robitussin).

The thing you want to look out for are not doubling up acetaminophen, and not taking any combination of aspirin + naproxen + ibuprofen.

They didn't say opioids are no better than acetaminophen+ibuprofen, but codeine, which is weak enough to be freely available OTC in many countries.

Anyone doubting the merits of opioids in pain control should take a look at https://en.wikipedia.org/wiki/Equianalgesic - many of the voices in this debate will sorely regret their remarks if they ever experience real pain, which most people will at some point.

Watch out popping ibuprofen in large quantities, it is hepatoxic.

Isn't that Tylenol(the acetaminophen in it)? Ibruprofen screws up your kidneys I think.

You're right. Tylenol trashes the liver, Advil hurts the kidneys and intestinal system.

Ibuprofen can cause liver damage in higher doses. It appears to happen almost randomly though, which suggests something unusual to the patient prompts the reaction.

https://livertox.nih.gov/Ibuprofen.htm

I suspect that there is no comparison to opioids for chronic pain either.

Obviously that is a bad use case for them and you would be crazy to use them for chronic pain.

No, you wouldn't be crazy. You'd simply be following medical advice/what's best for your situation. For some chronic pain sufferers opioids are one of the only options (or is something that is used in addition to other methods/things to alleviate pain). For instance, many people with connective tissue disorders use opioids in addition to other physical methods (surgical, splints, etc)[1], and removing something like an opioid can make life untenable, and amounts to torture [2]

1) https://www.ncbi.nlm.nih.gov/pubmed/26497567

2) https://www.statnews.com/2016/07/15/chronic-pain-opioids-pat...

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