David Nelson Hand Surgery Greenbrae Marin hand specialist surgery of the hand orthopedics San Francisco

 

 


Back to Patient HomeFirst posted July 25, 2012 Last updated October 14, 2015

Managing Arthritis Pain without Narcotics

This protocol that has been effective for hundreds of my patients over a 22 year period

Arthritis pain is quite common and therefore we have a lot of experience managing it. The program that I have developed is also the program advocated by the Arthritis Foundation, and patients tell me that is has been very effective. One patient told me, "I decided to try the Tylenol + Alieve combo. Wow! I have not had an uninterrupted nights sleep in many years (maybe as much as 40 years) due to pain. I'm now on my 5th day of the two pill combo and had 5 nights of uninterrupted sleep. This is a first for me! THANK YOU!"

The program involves Tylenol (acetaminophen) and, if needed, a non-steroidal medications such as Aleve (naproxen sodium or Naprosyn). Please read through this entire page, even if you feel that Tylenol never helps you.

The #1 choice is Tylenol*, taken alone.

This is both my #1 choice as well as that of the Arthritis Foundation. The reason that it is the #1 choice is that Tylenol is effective, inexpensive, does not require a prescription, and safer than the non-steroidal anti-inflammatory medications such as Aleve* (Naprosyn, naproxen sodium), Advil (Motrin, ibuprofen), and others. The non-steroidal medications have a risk of stomach ulcers, which Tylenol does not. It is not an anti-inflammatory medication.

Tylenol comes in three formulations. (Tylenol is merely a brand of acetaminophen, and any brand works as well as any other; it is just easier to type Tylenol than acetaminophen.) Regular Tylenol is either 300 mg or 325 mg and lasts about 3-4 hours. Extra-strength Tylenol is 500 mg but still only lasts 3-4 hours. Tylenol Arthritis is 650 mg, but the key is that it is a sustained-release formulation that lasts about 8 to 12 hours. This is preferable, so that you do not get highs and lows (peaks and troughs) in your blood level, and hence its effectiveness is more even throughout the day. In addition, it is much easier to remember once or twice a day; almost no patient can remember every 3-4 hours. The maximum amount of Tylenol that you can take is 4000 mg/day (reduced on July 28, 2011, to 3000 mg/day from 4000 mg/day by Johnson & Johnson’s subdivision, McNeil, the manufacturer of the brand Tylenol; this is probably a liability defense maneuver, as the FDA still lists the maximum as 4000 mg/day.) Whatever the maximum, taking two Tylenol Arthritis pills per day is still only 1/3 the max dose of 3000 mg/day.

 

Medication in the blood

This graph shows the difference between taking regular Tylenol, which is short-acting,
and taking the Tylenol Arthritis, which is long-acting: the long acting medication
gives you a more sustained blood level of effective medication.

 

Medication blood level

This graph shows the effect of taking two short-acting pills at the same time.
There is more medication in your blood at the beginning (this may be
too high and lead to side effects), but the blood level of medication
goes away too quickly. This is why I recommend the long-acting
Tylenol Arthritis, not regular Tylenol.

 

Tylenol is quite safe, as long as it is taken as directed. The complications from Tylenol come from patients taking an overdose, often unintentionally: it is in so many over-the-counter medications. Tylenol is actually a very safe medication when taken as directed.

The #2 choice is Tylenol + NSAID together

The #2 choice is to combine Tylenol Arthritis with a non-steroidal anti-inflammatory medication (the abbreviation for this is NSAID). The combination is more effected than either medication alone. This is called "synergy", and can be thought of as a case of 1 +1 = 3, not 2. The recommendation is to continue taking the Tylenol Arthritis and also to take a sustained-release NSAID.

Aleve is my usual choice, as it is a sustained-release medication that also is safe, effective, does not require a prescription, and inexpensive, 220 mg. Max is three per day; two is a reasonable dose.

Summary

So, putting all of this together: First, try the Tylenol Arthritis alone, one pill in the morning. If this works in the morning but by the afternoon or bedtime you are hurting again, take one in the morning and one in the afternoon or evening. If you only hurt at night, take it at bedtime or about one hour before.

If this does not give you an adequate level of pain relief, switch to the two-medication method, the #2 choice discussed above. Start with one Tylenol Arthritis plus one Aleve per day in the morning for daytime pain; if this works for the morning but you hurt later in the day with this morning dosing, take one of each twice a day. If you only hurt at night, you can take them at bedtime or about one hour before. The goal is to take as little as you can per day, even skipping a day or more if you do not hurt (this is called a “drug holiday”) and yet get the pain relief you need to enjoy life.

* Tylenol is the brand name owned by McNeil Company for the medication acetaminophen; Aleve is the brand name owned by Bayer for the medication naproxen sodium, the active ingredient in Naprosyn, which is the brand name owned by Hoffmann-LaRoche. You can use any brand or generic for either acetaminophen or naproxen sodium. For a time, Tylenol brand acetaminophen has been off the market, due to manufacturing problems at the McNeil plant. It is OK to use any brand of acetaminophen arthritis, 650 mg. It is made by CVS, Safeway, Costco, etc.

Would you like to search the medical library of the National Library of Medicine for scientific papers on this topic? Just click on the Pub - Med image:
Remember the admonition from the Patient Education Links Page: the Internet has a lot of information, much of it incorrect. I have reviewed the sites that I have linked to, and have only linked to sites when I personally know the surgeon who posted it, or am a member of the organization that posted it. However, I may not agree with all that is on that site, and it may have changed since I reviewed it. If any of the information is not consistent with what I have told you, please download the material and bring it in.