Diplomate, Board Certification of Emergency Medicine
Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua
Hospital
We will continue with evidence based medicine (EBM) in the
future, but I wanted to discuss another issue, that of pain
relief. Many years ago, and most of us remember this, there
was no mild pain relief available other than paracetamol (in
the USA called acetaminophen) and aspirin. In Europe, a drug
called dipyrone -- also known as optalgin -- was available.
Optalgin, to this day, has not been approved in the USA. It
can cause shock and can anemia, though there is some
literature that says this effect is rare and that this drug
may be safer than others currently on the market.
Acamol is the only drug in its class, and it is very
effective. It lowers fever and treats pain well and, when
combined with narcotics, gives a combination that is more
effective than either drug alone. It is safe in the elderly
and does not affect the kidneys or cause bleeding.
It is safe in pregnancy and in little children as well.
Because it is available without prescription, many people
believe it is less effective than prescription drugs. This is
just not true. Often it is the best choice for pain. It has
no anti-inflammation effects which, as we will soon see, may
be to your advantage. An overdose can be lethal. It causes
liver failure when taken in massive doses. The correct dose
is a question. In children, 15 to 20 mg/kg is safe and
effective, while in adults we generally give 1000 mg.
Aspirin is great for pain and has other effects that are
helpful as well. It is a very old drug and comes from the
bark of a tree in South America. It poisons the platelets --
the cells which control clotting -- so that clotting is
slowed. This effect is important to prevent the clotting that
can cause a heart attack and stroke. All people over the age
of 35 should probably be taking one low-dose aspirin a day.
All people with chest pain and heart attack get this drug as
well.
It is the cornerstone of treatment in rheumatic arthritis and
osteoarthritis, and often these people are on superhuman
dosages. It can cause bleeding in the stomach and affects the
kidneys. It relieves fever as well, but it has been
associated with Reye's syndrome (a serious liver disease) in
children with viral infections, and particularly chicken pox.
Therefore it has fallen out of use for kids with fever.
Newer drugs for pain came out in the seventies. These drugs,
called NSAIDs, were effective pain relievers and fever
reducers. They were not overly dangerous in overdose and did
not cause Reye's syndrome. The first was indomethacin, also
known as indocin, soon followed by ibuprofen and naproxen.
These drugs are also sold now without prescription, but the
safety factor is still a consideration. These drugs do cause
bleeding in the stomach and kidney failure. More next week.
Write me in care of the Yated.
A message from GlaxoSmithKline, sponsor of this
column. Eczema can cause unrelenting itching, but you may
not wish to use a high-powered cream that may have side
effects. Betnovate is mild yet effective. Since eczema is
often a children's disease, this point is important. Safe for
the elderly as well.
