As part of her marathon training, Daisy Carranza has taken an over-the counter pain reliever nearly every day for the last several months.
On race day Sunday, she's prepared to pop at least seven Extra Strength Tylenol capsules: two at the starting line, three at mile 18 — just before the body starts to rebel — and two at the post-race party, to help with recovery.
Bank of America Chicago Marathon. "I have a lot of knee, back and shoulder pain, so I look at Tylenol in the same way as protein bars and Gatorade."
Like lucky caps and favorite shoes, marathoners often rely on over-the-counter pain relievers to get them through the endless training and the grueling 26.2-mile race. The most popular drugs generally contain acetaminophen — the active ingredient in Carranza's Tylenol — or ibuprofen, part of a class of medicines called NSAIDs, or non-steroidal anti-inflammatory drugs.
The medicines can be a godsend when taken as directed for headaches, fevers or acute injuries, such as a twisted ankle. But ibuprofen and acetaminophen pose well-documented health risks, especially when they're consumed in large amounts or for an extended time.
There's also little evidence to suggest that athletes get any benefit from taking pain relievers before a race. And emerging research is starting to show that ibuprofen can actually cause inflammation under certain conditions and may interfere with the body's processes of recovery and adaptation.
"We fall into the assumption that anything available over the counter is safe and that we know how to use it," said Wendy Kohrt, a professor of medicine at the University of Colorado Anschutz Medical Campus who has studied NSAIDs' effects on bone formation. "But it's just not true."
When taken preventively, pain relievers "have the potential to reduce how well your tissues adapt to the exercise," said Stuart Warden, an associate professor in the Indiana University School of Health and Rehabilitation Sciences. "We all know exercise makes muscles bigger, bones stronger and tissues adapt, changing in structure," he said. "NSAIDs block a pathway that's important for that adaptation."
Athletes in all sports and at all levels swear by over-the-counter painkillers, especially ibuprofen, which is known by its fans as "Vitamin I." A 2008 survey of participants in an Ironman triathlon in Brazil found that almost 60 percent reported using NSAIDs in the three months leading up to the event, according to a study in the British Journal of Sports Medicine. Almost half reported taking pills during the race.
Another report that looked at medicine use by male soccer players competing in the 2002 and 2006 World Cups called the high intake of NSAIDs "alarming."
Chicago's Devin Schuyler, 33, said she uses ibuprofen before and sometimes during all runs longer than nine miles. For Sunday's marathon, she plans to take 800 milligrams 30 minutes before the start and another 800 milligrams or so about three hours into the race. The drugs help keep her muscles and joints feeling loose "and to prevent the onslaught of pain that would slow me down," she said.
When she doesn't take ibuprofen, Schuyler said she feels stiff and sore during the race and her running form falls apart, causing more post-race pain. Plus, "pain can be a distraction — it can really throw my mental game off," she said.
Schuyler knows taking painkillers has risks, and she's been told by doctors and coaches not to do it. "But I find that I listen to my body well enough to know if it's an all-right choice for me to make or not," she said.
Athletes often take pain relievers to help cope with pain after intense exercise, including a condition called delayed-onset muscle soreness. But NSAIDs haven't been shown to help with that problem, Warden said. Instead, runners should try gentle exercise, such as using a stationary bike or running in water, he said. Sprinting and normal running should be avoided.
Ibuprofen (Advil and Motrin) and another NSAID, naproxen (Aleve), are recommended for relieving pain and reducing fever. Best tolerated when taken on a full stomach — rare during a marathon — they work by stopping the body's production of substances that cause pain, fever and inflammation.
But one of those substance, prostaglandin, is also important for the synthesis of collagen, Warden said. "Collagen is the main structural material of all muscles, bones and tendons," he said. "That's what gives (them) strength. The drugs can reduce how much collagen you form in response to exercise."
Acetaminophen has a weaker anti-inflammatory effect than NSAIDs and is often classified as an analgesic, or pain reliever. The drug changes the way the body senses pain and has a cooling effect, according to the National Institutes of Health.
Both types of medicines have risks and potential side effects, especially when misused. (Experts are less concerned about aspirin, also an NSAID, but say it's best to avoid routinely taking any kind of painkiller before running.)
With the exception of aspirin, NSAIDs can increase the risk of heart attack and stroke. They also can cause gastrointestinal pains and pose risks to the kidneys. Dehydration can stress the kidneys even more.
"There's absolutely a role for anti-inflammatories like Motrin, Advil and Aleve, but you have to understand when they're necessary and when you should take them, said Dr. George Chiampas, medical director for the Chicago Marathon. "And more is definitely not better."
Taking too much acetaminophen — a common mistake because it's often found in combination products — can cause liver damage. Last year, Tylenol's manufacturer lowered the recommended daily maximum dose of Extra Strength Tylenol from eight 500-milligram tablets to six to reduce the risk of an accidental overdose.
Soreness is one of the least welcome side effects of exercise, but the pain is a signal that some tissue irritation or damage has occurred, Warden said. Masking that pain can lead to a more serious injury.
By the same token, inflammation is a natural part of the healing process and speeds up tissue repair. Chemicals released at the injured site attract cells that will clean up the area and heal it, Warden said.
The inflammation response often is overzealous, Warden said, and drugs can be used to control it. "But once the inflammatory signs are gone, you don't need anti-inflammatories," he said.
Race organizers are increasingly discouraging the prophylactic use of ibuprofen because of its effect on the kidneys. At the Chicago Marathon, medical staffers won't dispense ibuprofen or naproxen on race day because the drugs could affect the gastrointestinal tract or the kidneys, especially if dehydration is a factor, said Chiampas, an assistant professor in the department of emergency medicine and sports medicine at Northwestern University's Feinberg School of Medicine. Runners who need pain relief may get acetaminophen.
"No one should be taking NSAIDs for months at a time," Chiampas said. "You're putting yourself at risk for an ulcer, for GI issues or kidney problems. If you are, you need to reassess that injury and why you are taking these."
When David Nieman studied ultramarathoners competing in the 100-mile Western States Endurance Run, he found that runners who took over-the-counter ibuprofen before and during the race had noticeably more inflammation than other runners.
Nieman, director of the Human Performance Laboratory at Appalachian State University in Boone, N.C., also found the ibuprofen users showed signs of reduced kidney function and increased oxidative stress. Afterward, the runners had the same degree of muscle damage and soreness whether they took ibuprofen or not.
"I tell runners, (the drugs) are not doing what you think and are actually hurting you by leading to mild inflammation and kidney dysfunction," said Nieman, who has run 59 marathons and ultramarathons. "Ibuprofen and heavy exertion do not mix well. I don't recommend any athlete uses ibuprofen; it's amazing how it has taken over the running community."
One recent paper, published in the Clinical Journal of Pain and funded by the makers of Tylenol, did find that Tylenol is effective for treating post-marathon soreness. Another small study reported that Tylenol improved performance in cyclists by blocking pain.
Carranza said she has heard reports of the dangers of overusing painkillers, but she loves running too much to stop.
"I know it's not good," she said, echoing a common sentiment among her fellow marathoners. "But I'd rather cover the pain and keep running. I'm addicted."