OTC Cases: Acute Aches and Pains

Case 1

Pain in a Patient With Heavy Alcohol Use

Caleb is a construction worker aged 24 years who comes to the pharmacy after work. He is dusty and clearly tired, but he also has breath and body odor, suggesting he may have been drinking (it is only 3:45 pm). He reports having had shoulder pain for several days, mostly because his crew has been installing a very heavy supporting beam during a home renovation. He says this happens occasionally, and he just needs something for a few days. If possible, he would prefer not to have to take any doses while at work.

A: Upon gentle questioning, Caleb says that he and the guys stop for a beer (or 2) on the way home every day. He also says he may have another beer or 2 when he gets home. For that reason, the pharmacists decided to rule out acetaminophen as an option because it is hepatically metabolized and poses a risk of liver toxicity at lower thresholds in heavy drinkers.^1,2 Caleb’s pain has been present for several days, suggesting inflammation rather than acute injury. A nonsteroidal anti-inflammatory drug (NSAID) is a cautious option, and the pharmacist recommends naproxen 220 mg twice daily with food due to its long half-life. He warns Caleb that naproxen can irritate the stomach, so Caleb should take it with food and consider avoiding alcohol while taking the naproxen.³ He also counsels Caleb that this should be a short-term intervention, and if the soreness continues, he should see a health care provider who can conduct an assessment.

Case 2

Back Pain in a Patient With Cardiovascular Disease

Anthony is a man aged 62 years with a history of myocardial infarction and heart failure. He has a backache that he attributes to sleeping on a weird mattress at his son’s house for a few days. He’s back home now and expects sleeping on his firmer mattress will help, but he wants something for the pain, especially at night.

A: NSAIDs (especially at higher doses or prolonged use) can increase the risk of cardiovascular events and worsen heart failure through fluid retention.³ Anthony rates his pain as about 4 on a scale of 1 to 10 (where 10 is the worst pain). The pharmacist recommends acetaminophen and suggests scheduling doses around the clock for 2 days.⁴ In addition, he discusses using warm or cold compresses if they help, but only for 10 minutes at a time, once every hour, so Anthony doesn’t fry or freeze his skin.⁵ He also counsels Anthony to move around as much as he can and to consider finding a massage therapist who specializes in pain if he thinks it will help.⁵

Case 3

Headache in a Patient With GI Bleeding History

Sherrie is a 55-year-old woman with a headache. She says she rarely experiences headaches and has no in-date analgesics at home. When the pharmacist looks at her prescription drug profile, he sees that Sherrie had a serious gastrointestinal (GI) bleed while taking a bisphosphonate 3 years ago. She has no visual disturbance or systemic pain and says that she went to a concert with her son and developed the headache from the very loud music.

A: Sherrie’s previous bleed puts her at high risk for a recurrence. For this reason, NSAIDS and aspirin are contraindicated.^3-5 Acetaminophen is the analgesic of choice. It does not increase the risk of GI bleeding and is effective for mild to moderate headaches. She uses analgesics infrequently, lowering concerns about cumulative toxicity. He counsels her to take one or two 500-mg gel caps every 4 to 6 hours and never to exceed 6 gel caps in a day.⁴ He also asks about her other medications to ensure she is not taking acetaminophen in a combination product and is pleased to learn she takes nothing that contains acetaminophen.

Case 4

Localized Musculoskeletal Pain in a Patient With Multiple Systemic Comorbidities

Cindy is a woman aged 72 years with type 2 diabetes (with recent peripheral neuropathy), chronic kidney disease (CKD), and a history of heart failure. She is well known to the pharmacist and asks for something to help with localized knee pain. When questioned, she says that she banged her knee on the trailer hitch of her husband’s truck. The area is bruised and swollen, but the skin is intact. She indicates that she tries to minimize her use of acetaminophen.

A: Oral NSAIDs are problematic due to Cindy’s CKD and heart failure (renal and fluid-retention risks). In addition, systemic exposure to analgesics increases the risk of adverse effects in older adults with multiple chronic conditions.³ After looking at the various options, the pharmacist recommends short-term use of topical diclofenac.⁶ She emphasizes that topical therapies provide local pain relief with minimal systemic absorption; only 5% to 10% of diclofenac is systemically absorbed (but systemic exposure is not zero), reducing renal, cardiovascular, and GI risks.⁶ She advises Cindy to apply cold or warm packs (using whichever provides the best relief) and apply the diclofenac only to the affected area 4 times daily. Cindy should follow up with a prescriber if pain persists.⁶

About the Author

Jeannette Y. Wick, MBA, RPh, FASCP, is the director of the Office of Pharmacy Professional Development at the University of Connecticut.

REFERENCES

1. Eledu P. Relationship of Acetaminophen and Alcohol to Incipient Renal Insufficiency: The Role of Race in Estimating Glomerular Filtration Insufficiency: The Role of Race in Estimating Glomerular Filtration Rate. Walden Dissertations and Doctoral Studies. 2023. Accessed January 20, 2026. https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=12944&context=dissertations

2. Acetaminophen and ethanol drug interaction report. News release. Drugs.com. Accessed January 20, 2026. https://www.drugs.com/interactions-check.php?drug_list=64-15289,1034-14582

3. Naprelan (naproxen sodium) controlled-release tablets. Prescribing information. Almatica Pharma; 2017. Accessed January 20, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020353s034lbl.pdf

4. Tylenol Extra Strength gels. Tylenol. Accessed January 20, 2026. https://www.tylenol.com/products/headache-pain-relief/tylenol-rapid-release-gels

5. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367

6. Voltaren gel (diclofenac sodium topical gel). Prescribing information. Novartis; 2009. Accessed January 20, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022122s006lbl.pdf