Painkillers Used During Ultramarathons

Authors: Chris Hall, MD and Brian Krabak, MD MBA

Introduction

Pain relief is one of the commonest reasons for a visit to the medical tent during a RacingThePlanet / 4 Deserts event. Even in the absence of injuries, taxing races like these can be expected to produce discomfort which can be eased through the use of a variety of pain killers. Many of these are available over the counter, making them options for competitors even without medical consultation. The following is a review of some of the common medications that race participants might consider packing with them before hitting the trail. You should discuss all medications with the medical staff prior to starting a race. This information will be crucial for managing any potential medical issues.

Paracetamol (Acetaminophen)

This is one of the commonest over-the-counter medications available, and goes by a wide number of trade names, including Tylenol, Panadol, Anacin, Efferalgan, and many others. While it is generally regarded as one of the weaker painkillers, it can be effective for low-grade muscle aches and headaches, and carries the benefit of also treating fevers quite well. It also has relatively few side effects when taken as prescribed, and very few people are allergic to it.

CAUTION: Paracetamol is processed through the liver. Overuse of Paracetamol can lead to liver failure, especially in individuals with liver disease or heavy alcohol use.

Non-Steroidal Anti-Inflammatory Drugs (‘NSAIDs’)

This group of medications is extremely diverse and includes acetylsalicylic acid (also known as ‘ASA’), ibuprofen, naproxen, ketorolac, and many others. Ibuprofen and ASA are the most commonly used of these and are marketed under many trade names, including Aspirin and Excedrin (for ASA), and Advil, Nurofen, Motrin, and Brufen (for ibuprofen). These medications act throughout the body to reduce inflammation, and can be used for a wide variety of moderately painful conditions, including muscular injuries, headaches, fevers, and various medical conditions (they even work well for kidney stones and gallstones!). NSAIDs are also available in topical applications (e.g. – gels, ointments), which allows the medication to be applied directly to the area experiencing pain. Generally considered to be stronger painkillers than acetaminophen, NSAIDs and ASA also carry a larger risk of side effects. In particular, anyone with a history of stomach ulcers or chronic kidney disease, or who take blood thinners such as Coumadin (‘Warfarin’) should avoid these drugs altogether. People with a history of asthma should also be cautious, as NSAIDs and ASA can cause asthma attacks in some people with this condition. 

CAUTION: Athletes competing in a race should use NSAIDs with caution, as it is not uncommon to become dehydrated while competing. Dehydration can affect kidney function, which could be worsening with use of NSAIDs. Severe dehydration with NSAID use can lead to kidney failure.

Anti-Spasmodics

Drugs with muscle relaxing qualities are often used for conditions resulting in strong muscle spasms, such as chronic lower back pain related to arthritis or degenerative spinal discs. This includes agents such as cyclobenzaprine (e.g. – ‘Flexeril’) and methocarbamol (e.g. - ‘Robaxin’). They are available in over-the-counter products, often in combination with acetaminophen or ibuprofen. They have little use for most acute musculoskeletal injuries, but competitors with chronic back pain might consider bringing a small supply if they have found these medications to be useful for painful flare-ups in the past.

CAUTION: Muscle Relaxant side effects include sedation. It is extremely dangerous to utilize a potentially sedating medication while competing in these extreme environments.

Opioids

This is a diverse group of drugs which all share similar characteristics with morphine, which is derived from opium (produced by the poppy plant). Commonly-used agents in this class of medications include codeine, morphine, and oxycodone. While their potency varies from drug to drug, opioids are generally considered to be more potent than either NSAIDs or acetaminophen, and are usually prescribed only for severe pain. In most countries access to these drugs is legally restricted, and a physician’s prescription is usually required to obtain them. Codeine is one opioid which is available in many countries without a prescription, typically as part of a low-dose combination medication (e.g. – acetaminophen plus codeine). The primary reasons that access to these medications is so heavily restricted are the potential for serious side effects, and concerns over dependency and/or abuse. When taken in higher doses, opioids can cause somnolence, lethargy, or even coma, and these drugs can depress respiratory efforts to the point where breathing might even cease. In general, this class of drugs should not be considered for routine use by competitors while on the course; anyone entertaining their use should consult their personal physician prior to doing so.

CAUTION: As mentioned above, side effects include sedation and respiratory compromise. It is extremely dangerous to utilize a potentially sedating medication while competing in these extreme environments.

Combination Medications

As mentioned above, it is a common practice for many pharmaceutical companies to package two or more medications into a single product. Commonly-used agents include acetaminophen, ibuprofen, and codeine. Caffeine is also frequently packaged into products targeted towards headache relief. The theoretical upside to this practice is that the various ingredients can work in synergy to provide better pain relief; on the other hand, it can also make self-prescription trickier if one isn’t careful about reading the ingredients in a given product.

CAUTION: Caution is especially warranted since many combination products share trade names which are very similar to single-ingredient formulations.

Summary

A large number of medications are available over the counter which carry little risk of side effects and can be effective for mild to moderate pain. Competitors are always welcome to discuss any painful conditions with the medical staff, but having a small supply of one of these medications available for self-use while on the course is probably well worth the small amount of space and weight they occupy.