Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?
A:Â Frequent aches and pains are a common problem for older adults.
If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be a sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pain if you can help her doctors identify the underlying causes of her pain.
That said, it’s a good idea to ask what over-the-counter (OTC) pain relievers are safest for older people.
That’s because improper use of OTC painkiller tablets is actually a major cause of harm to older adults.
So let me tell you what OTC pain relievers geriatricians usually consider the safest, and which very common group of painkillers can cause serious side-effects in aging adults.
What’s the safest OTC painkiller for an aging parent?
For most older adults, the safest oral OTC analgesic drug for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.
Acetaminophen is usually called paracetamol outside the U.S.
It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.
The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdose cases are accidental.
But when taken at recommended doses, acetaminophen has surprisingly few serious side effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.
Also safe for pain relief in aging: over-the-counter topical analgesics
Another option to consider are topical analgesics creams; a variety of them are available over-the-counter. I generally recommend trying a few different ones, to see which one seems to provide better relief for a particular person.
Be careful or avoid oral over-the-counter anti-inflammatory drugs
At the drugstore, the most common alternatives to acetaminophen are painkiller tablets such as ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).
Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.
Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs cause side effects that are especially likely to become dangerous as people get older. These include:
- Increased risk of bleeding in the stomach, small bowel, or colon. Older adults who take a daily aspirin or a blood thinner are at especially high risk.
- Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
- Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
- Interference with high blood pressure medications.
- Fluid retention and increased risk of heart failure.
Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.
Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).
Because of these well-known serious side effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, oral NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution. (For more on the Beer’s list, see this article: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria 2023 Update.)
Now, it’s important to know NSAIDs can also be prescribed as creams or gels. These topical forms are much safer, and can be effective for pain relief. (In fact, as of 2020, the topical NSAID Voltaren gel is now available without a prescription.)
Despite the well-established risks of oral NSAIDs, NSAID painkiller tablets are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.
(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of serious side effects, unless they are used as a cream or gel, in which case the risks are much less.)
Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.
I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.
A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.
This is not to say that older adults should never use NSAIDs. They are often more effective pain relievers than acetaminophen, especially for conditions such as arthritis. So even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks.
But this conclusion really should be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other dangerous side effects. (It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.)
Unfortunately, far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.
Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.
Aspirin: a special NSAID we no longer use for pain
Aspirin is another analgesic drug available over-the-counter.
It’s technically also an NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.
(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)
Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.
Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.
Note: A daily baby aspirin also used to be recommended for the primary prevention of heart disease. However, because research showed that in older adults, the risk of bleeding was often higher than the expected protection of a baby aspirin, the US Preventive Services Task Force no longer recommends a daily aspirin for primary prevention in older adults. (A daily aspirin is still however often recommended for those older adults who have already had a heart attack or stroke.)
FAQ: What’s the strongest OTC painkiller?
I’m also sometimes asked what is the “strongest” available over-the-counter analgesic drug.Â
To be honest, for many aches and pains, most people seem to find anti-inflammatory analgesic drugs (also known as NSAIDs) more effective for pain relief than acetaminophen. This can be especially true if one takes a higher dose, such as 600mg of ibuprofen.
The problem, of course, is that higher doses (and more frequent doses) of NSAIDs create higher risks for older adults.Â
For this reason, I discourage older adults and their families from trying to get the “strongest” oral OTC pain reliever.
Tips on safer use of OTC painkillers
In short, the safest oral OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.
If you have any concerns about liver function or alcohol use, plan to use the medication daily on an ongoing basis, or otherwise want to err on the safer side, try to not exceed 2,000 mg per day, and seek medical input as soon as possible.
It is also generally safe to treat pain with over-the-counter topical analgesics. Although oral anti-inflammatory drugs such as ibuprofen are risky in older adults, an OTC topical NSAID such as Voltaren is usually safe.
You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain.
And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask. For example, chronic pain self-management programs can be very helpful to some people. Physical therapy, massage, and certain forms of exercise can play an important role in pain relief, especially when it comes to chronic pain.
Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medications of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.
Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain health. (See 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution for more about the risks of anticholinergic drugs.)
My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.
If acetaminophen isn’t providing enough pain relief
If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.
You may also want to ask about prescription topical painkillers, such as gels, creams, and patches. These are generally safer than oral medications, because less of the body is exposed to side effects.
For severe pain, it may also be reasonable to discuss other prescription drug options. Depending on the type of pain, in some cases it can be reasonable to consider using very small doses of opioids, or other types of painkillers. That said, bear in mind that all prescription pain relievers come with risks and can cause serious side effects. In older adults, most will affect brain function and balance.
The truth is that it’s often not possible to treat pain effectively and 100% safely, when it comes to using oral painkiller tablets. But by being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from pain relievers.
Good luck!
This article was reviewed & updated in August of 2024.
[As we are approaching 200 comments, comments have been closed.]
Jean says
I’m an old person, how can I alleviate the pain I have? I have been diagnosed with inflammation of my ribs, the cartilage is swollen and very painful. ( Costochondritis)
Nicole Didyk, MD says
Costochondritis is inflammation of the cartilage in the joints where your ribs meet your breastbone. It is painful and can be caused by trauma (being hit in the chest) or excessive coughing.
Treatment can start with a warm compress and stretches. Medications that can be helpful include pain-relieving creams (containing capsaicin, NSAIDs or numbing medication), or oral pain meds like acetaminophen or ibuprofen. We use ibuprofen and other NSAIDs with caution in older adults, as they can affect kidneys and blood pressure, and increase the risk of stomach irritation and bleeding.
It can take up to a few weeks for the pain of costochondritis to subside. If it gets worse or is accompanied by pother symptoms like shortness of breath, cough, fever or coughing blood, I would advise seeking medical attention right away.
Lori says
Can meloxicam cause memory lose. I realize it’s an nsaid, I take it intermittently for a painful hip. I heard it is not effective if it’s not taken daily, any truth to that?
It does help allot with my hip pain. I’ve tried several different shots in the(GTB), dry needling and months of physical therapy. It keeps coming back, worse at night while sleeping.
If I take mobic as needed will it work or do I have to take on a regular basis?
Thank you!
Nicole Didyk, MD says
Mobicox (meloxicam) is a newer NSAID that acts on the COX-2 enzyme and seems to be less likely to cause gastrointestinal bleeding, although it still can. We generally avoid them for long term use on older adults, because they can affect the kidneys, worsen heart failure and edema, and increase bleeding risk.
Meloxicam can work if taken occasionally, or for a few days or weeks at a time, but some need to take them every day long term. It’s good to use other methods like physiotherapy, exercise and topical or injectable treatments to spare the meloxicam use.
In terms of memory loss, meloxicam has actually been studied in rats to see if it can reduce brain inflammation and be protective of neurons, but we don’t have enough information to recommend it for that use in humans.
Stephen Davis says
I’m 66 with heart failure that hasn’t progressed, cirrhosis from fatty liver and T2. I also have psoriasis and psoriatic arthritis. All of that said, I do have inflammatory flare ups but usually can handle the discomfort. About half a dozen times a year if I have a flu or something that causes aches and fever, I will take an inpuprofin or naproxen once or twice at 200mg but avoid acetaminophen because of my liver. Does this infrequent usage carry much risk?
Nicole Didyk, MD says
I’m not sure what “T2” refers to (maybe taking Tylenol #2?), but thanks for describing your other health issues.
The potential issue with taking an NSAID like ibuprofen or naproxen with conditions like cirrhosis and heart failure, is the fluid retnetion and kidney strain that those medicaitons can cause. A higher dose and longer duration of use is more risky than if you only take a few doses a month, but it’s best completely avoided.
Talking to your doctor or pharmacist could help you decide if the trade off of risk vs benefit is worth it for you.
Darby Bemrose says
Can pain meds like Aleve raise potassium levels?
Nicole Didyk, MD says
NSAIDs like Aleve and Advil can interfere with the synthesis of prostaglandin and this can raise potassium levels. It’s more likely to happen if someone is also living with kidney impairment, dehydration or heart failure. I found an article that explains this here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894511/
Ian says
Unfortunately my wife and I have always found paracetamol to be completely useless as a painkiller. We don’t reach for aspirin because it is what we’re used to, but because it actually works where paracetamol does nothing at all. In my case it has never worked. It was what my parents gave me as a child, because of potential risks associated with aspirin in children, but it never did anything. It was only as an adult that I realised what pain relief actually was because I switched to the alternatives.
This all makes things quite tricky. Opioids are addictive, NSAIDS are bad for the stomach and intestines and paracetamol is ineffective.
Nicole Didyk, MD says
Many patients of mine, and the scientific literature, would agree that paracetamol (acetaminophen) is not very effective for arthritis pain for most people. You’re right about the hazards of opioids and NSAIDs as well.
Other medication alternatives include COX-2 inhibitors (like meloxicam for example), which have a lower GI bleeding risk than NSAIDs, and some antidepressants or ant seizure medications like duloxetine or pregabalin. This article from the Mayo clinic does a good review of some pain mediations: https://www.mayoclinic.org/chronic-pain-medication-decisions/art-20360371
The other part of pain management is non-medication strategies like exercise, weight management, mindfulness, stress reduction and physiotherapy and other professional input.
valerie morgan says
It’s absolutely outrageous that this doctor is advocating the use of tylenol for pain relief . much research has proven that it works no better than placebo for pain relief…. and it is very bad on the liver. i wonder why she would then prescribe it for elderly patients. why she would prescribe it for anyone. but especially elderly who are less likely to complain. i am not among them. i complained . i did the research. acetaminophen….. tylenol whatever it’s called … anywhere in the world … is the biggest con job in american medicine. i have polyarticular bone to bone osteoarthritis so bad i was prescribed the morphine pain patch. i couldnt use it because it made me cry .. nonstop. im still searching for relief i might have to chose between the side effects of celebrex or mobic… but with either i get some pain relief. its my body. my quality of life . i have not one moment or movement free of pain. and i have my share of horror stories about the state of medical care in this country. for years my progressing arthritis went undiagnosed because no one would order xrays. it was easier for them to tell me i had … fibromyalgia. yeah. i’ll stop there . oh wait yes i know fibromyalgis is real.. to them… but there is no damage to the body. zip. its mostly mental. and all poor women, whatever our color are chronic malingerers. i didnt get a series of xrays until i was .. 60 years old.its… everywhere. it hurt to type this. . ive also used aspirin , ibuprofen, naproxen, and given tramodol until i realized it is a narcotic. every single one of them provided some measure of relief. but tylenol was worthless.i expect it will take another 10 years until that is common knowledge to drs. and even then, well, i wont hold my breath. they don’t like admitting mistakes.
Nicole Didyk, MD says
Hi Valerie and thanks for sharing your experience. I’m sorry that you’ve had a difficult time getting effective help for your osteoarthritis, and that you haven’t felt heard by your providers.
You’re correct that acetaminophen seems to be pretty ineffective for hip and knee OA, as based on this systematic review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388567/, but there is a small effect, and the side effects are few for most people. Thus, in many pain management guidelines, acetaminophen is the first line of treatment. The critical thing is to evaluate if the acetaminophen is working and try something else, after discussing it with the patient.
As you point out, there are many side effects and risks with narcotics as well. OA management should best be holistic, but getting access to all of the non-medication treatments that would help is not easy.
Leonard J. R. says
IL am a 75 y.o. man. November of 2013, I was invaded by e-coli bacteria. After studying me, 2 different neurologist agreed, that the e-coli had left the small intestine and invaded the spinal nerve sack. Around the D-4 or D-5. One of the problem I have, is that I have upper body jerks. At night I take a 300mg Gabepentin, a 50/200 carbidopa/levodopa and a 650mg. Tylenol. I normally get 5 hours of sleep, before the jerking starts again. However, I was told to stop taking the Tylenol after 10 days and then start again after 30 days. It seems C&L pill stopped working a couple of years ago. My PCP is to busy to study the problem and won’t give other neurologists a referral, saying more study isn’t needed. My question to you. What chemical or herbal medicine would help me? Thank you so much!
Nicole Didyk, MD says
It sounds like you’re describing myoclonus, which can occur after a severe neurological infection. The treatment is usually with an anti-seizure medication (like gabapentin) or a sedative-hypnotic like clonazepam for example. I’m not sure where the Tylenol fits in, unless that’s related to some nighttime pain.
If your regimen has stopped working for you then it’s important to review whether something else has changed in your life: medications, habits, or another medical issue. I didn’t find anything about herbal remedies for myoclonus in my quick literature review, and I would really suggest talking to a doctor who knows your whole story to figure out the next steps.
Bob says
Great article! You provided a thorough explanation of the nsaid/painkiller subject matter. Thank you.
Nicole Didyk, MD says
I’m so glad you enjoyed the article! Let us know what other topics you’d like to see covered.
Tom says
This is completely crazy. Tylenol is useless. I have never had Tylenol to prove to reduce anything. Thus far for me, only powdered aspirin with milk is the only thing that helps to continue to buffer pain with the inclusion of Norco and Morphine which I take daily for severe pain. I have been using this combination for years. So far I have been kept comfortable. The aspirin is not required on a daily basis, maybe once or twice a week.
My wife has been suffering from severe pain and Dr. will not provide any medication beyond Tylenol which is useless to her. I coaxed her into aspirin which gave her far more relief than Tylenol does but the pain has been really miserable and makes it very hard for me also, watching her suffer in this manner. A simple prescription for her during this period would be at the least a Tylenol 3 but Dr will not even prescribe this.
All doctors seem to be terrified of the DEA if they make even one or two prescriptions. I have been fortunate to have a doctor who is not terrified of the DEA over his prescriptions for me and others like me. Our pain is well documented. My wife is alternating Aleve, Advil, aspirin. I am hoping that soon she will be able to remove all of these as with the passing days the pain is showing some signs of abating as she uses also Lidocaine patches and creams and now a product of Voltran.
Nicole Didyk, MD says
Thanks for taking the time to comment and share your experience and that of your wife. I’m sorry that it’s been so difficult to get relief from your pain.
In my practice in Canada, I certainly use narcotics when needed, but I try to use the a smaller dose and monitor carefully. We also use narcotics in conjunction with other non-narcotic treatments when we can. Pain management is complex and often needs a team, which unfortunately can be hard to access.
If a person’s family doctor isn’t comfortable prescribing narcotics, they might be open to a referral to a pain clinic that they can collaborate with for expert guidance.
I’m glad to hear that the topical medications (patch and creams) are effective and I hope you get the help you need soon.
M Crovatt says
My daughter almost died from an accidental overdose of a drug that added Tylenol to another pain medication. She went into total liver failure and barely survived. The pharmaceutical company’s choice to add Tylenol was simply to make the other drug patentable and increase the pharmaceutical company’s profit. This is immoral, should be illegal and was almost lethal.
Nicole Didyk, MD says
I’m so sorry to hear about your daughter’s experience and I’m glad she recovered.
Acetaminophen (also called paracetamol, brand name Tylenol) is used by many older adults for pain from arthritis, but it’s important to be mindful of the maximum daily dose. Most Geriatricians I know suggest keeping the dose at less than 3000 mg a day. Here’s an article that might be helpful: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509082/