When the hurting starts, you reach for pain relief.

But what kind? A quick scan of the shelves of pain relievers at the local pharmacy reveals a mind-boggling array of options.

There's good old-fashioned Aspirin, once the pain-relief king of the medicine cabinet, now challenged by such upstarts as acetaminophen and ibuprofen.

There are the topical formulas: familiar standards like Ben Gay and Absorbine Jr., joined by an plethora of others, some with numerical handles such as A535 or 024; others conjuring images of more long-standing and natural remedies, like Lakota or Tigerbalm; and still more with oxymoronic monikers like Icy Hot.

A visit to the health-food store reveals an additional range of possibilities.

Many of these products have similar aromas, suggesting common ingredients; all have lines of fine print detailing what's in them and contraindications outlining who should or should not use them. How does the consumer know which will work, which is best? At $5 to $20 a pop, trial and error might come close to breaking the bank.

Forever Young tapped a couple of experts to develop guidelines, putting the question to Barry Power, director of practice development with the Canadian Pharmacists Association, and Aubrey Rickford, a naturopathic doctor and supervisor of pain management shifts at the Robert Schad Naturopathic Clinic in Toronto, the teaching clinic of the Canadian College of Naturopathic Medicine.

First, a couple of caveats and a word on our methodology. This discussion relates only to products available without a prescription from a medical doctor. Your doctor is the best source for information on prescription drugs. Power and Rickford maintain that in cases of long-term or chronic pain, patients should consult a doctor about treatment options.

Furthermore, Power stressed that when taking something new, even an over-the-counter product, it's a good idea to discuss it with the pharmacist to get advice on its use and to ensure there are no contraindications or conflicts with other health conditions and treatments. This is particularly important when the patient is taking other medications.

In Canada, drugs are regulated by Health Canada's Therapeutic Products

Directorate and so-called Natural Health Products are gradually coming under the regulation of the new NHP Directorate. In general, whether a drug must be prescribed by a doctor is determined by the potency of the drug, its potential addictiveness, possible side effects and other factors.

PILLS

For short-term pain relief or long-term use of over-the-counter products in consultation with a physician, there are basic rules to be aware of regarding the active ingredients in the products and how they work in the body.

"It's really more to do with the person taking the medications than the medications themselves," says Power.

Ibuprofen, for example, is an anti-inflammatory drug, one of a class known for exacerbating stomach problems and causing gastrointestinal bleeding, so should be avoided by those with such problems and also those with high blood pressure, he says.

Another factor to be aware of, he adds, is that many cold medications contain either ibuprofen or acetaminophen, so adding a pain reliever when taking those can result in dangerous double dosing. "You're increasing risks of side effects."

The pharmacist can be a valuable resource, Power says, advising that consumers ask about products and be sure to disclose what medications, both prescription and over-the-counter, they are already taking.

Acetasylic acid (Aspirin) and acetaminophen work in similar ways to control pain, by inhibiting the body's production of prostoglandins - hormone-like substances that are involved in the regulation of pain, fever and inflammation.

Ibuprofen belongs to the class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs) and works by reducing hormones that cause inflammation and pain in the body.

TOPICALS AND HERBALS

With the topical rubs and herbal remedies, it's more a matter of trial and error, Power says. Many people feel these are safer, even with those that contain Aspirin or an anti-inflammatory, because there is less absorption into the blood stream. However, they can still cause side effects since it's not ingestion of the drug into the stomach that causes the problem, but rather the mechanism that blocks chemicals in the body that protect the stomach, he explains. "It's less common, because the levels you get in the systemic circulation are a lot lower, but it's a possibility and something to keep in mind."

Most topical formulations that don't contain a drug like Aspirin work because one of the active ingredients, be it camphor or menthol or capsaicin, cause an irritation on the skin -- often responsible for that feeling of warmth -- that increases blood flow to the area and relieves the discomfort.

Such herbal preparations are generally safe and can be quite effective, says Rickford. There are certain standard ingredients that work to block pain, he says, the best being capsaicin and menthol. Capsaicin is cayenne pepper and often used to relieve pain of peripheral neuropathy since it produces the same effect as physical heat. In fact, Rickford says, it's generally present in very small percentages because otherwise it will cause uncomfortable burning. He says it's a popular treatment for both rheumatoid and osteo arthritis and can be applied up to about four times a day with good results.

Menthol is one of the essential oils used for pain relief, along with eucalyptus, rosemary and others, Rickford says. Menthol is a vasodilator that promotes better blood flow and is present in many of the creams and rubs sold over-the-counter but often not in a high enough amounts. The higher the concentrate the better, he says, noting that 16 to 20 per cent is optimal. The product 024 contains the highest percentage -- 24 per cent -- of any on the market and, thus, does a good job relieving pain, he says.

Other natural products include oral botanicals such as curcuma longa, in its common form the household spice turmeric -- "considered, of all the botanicals, the best anti-inflammatory," Rickford says. It acts in the same way as the popular arthritis drug Celebrex, blocking the cox-2 enzyme.

Curcuma, he says, can have beneficial effects on many chronic conditions that are affected by inflammation in the body, since it directly affects the inflammatory pathways.

Another oral botanical for pain relief is boswellia, which also works by blocking the pathways that lead to inflammation and pain. He says it's been shown to be particularly effective for osteo arthritis in the knees.

The other natural pain reliever that Rickford recommends is essential fatty acids, as found in fish oils. These also block certain inflammatory pathways and can be particularly effective used in combination with turmeric. "There you've got two things working on two different pathways. So they can do a better job if you combine them."

However, with the fish oil, he recommends taking it in liquid form rather than in capsules, which contain so little of the necessary linoleic and alpha-linolenic acids, EPA and DHA, that it's necessary to down several tablets to get a desired effect. Unlike the old, detested, cod liver oil, he says today's liquids are flavoured and much more palatable, particularly when kept cold and followed by a glass of juice. A couple of teaspoons a day is all you need, he adds.

Power notes that a popular natural pain remedy for arthritis is glucosamine, which has "a fair bit of evidence" to support its effectiveness. "It's probably the one that's been the best studied and it seems there is a growing body of evidence to support its use."

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PAIN ONLINE

Pain sufferers often aren't sure where to turn for help. Here are some resources to be found at your fingertips -- on in 'net:

BigBackPain.com -- a B.C.-based website dedicated to providing comprehensive and useful information for people without medical training.

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