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  1. While severe pain is a problem and must be handled, I personally feel that pain is over rated by the medical world and society. We as a society have decided that there should never be any pain. I find it more acceptable to regard pain as a normal body function and understand that it is the natural way to handle healing. I damaged my rotator cuff a few years back and they wanted to prescribe pain killers and schedule surgery for it. I did not use the pain killers nor did I have the surgery. It healed and while I still have some pain, if I had covered up the pain, I would have continued to damage the shoulder and it would not have healed. I also find the using a combination of over the counter pain killers more effective than a single one, ibuprofen followed a few hours later by aspirin seems to be more effective than only taking one of them. The Bible only condoned the use of the extreme pain killers of that time for the terminally ill. Proverbs 31:6 still is a good guide to the proper use of medication and a way to keep from becoming an addict, legal or illegal.

    1. Taking too much Ibuprofen will ruin your kidneys too…possibly due to the high blood pressure. I took a lot of ibuprofen over the years and have high blood pressure and bad kidneys…Take that into consideration if you have any kidney issues.

    2. The research articles I’ve seen only document a SMALL blood pressure increase, insignificant in my opinion.

      https://www.ncbi.nlm.nih.gov/pubmed/3475201 – “We conclude that ibuprofen at doses as high as 2400 mg/d for up to seven days has no effect on blood pressure in normotensive women.”

      https://www.ncbi.nlm.nih.gov/pubmed/23092442 – “NSAID users had a 2 mmHg increase in systolic blood pressure (95% CI, 0.7 to 3.3). Ibuprofen was associated with a 3 mmHg increase in systolic blood pressure compared to naproxen (95% CI, 0.5 to 4.6), and a 5 mmHg increase compared to celecoxib (95% CI, 0.4 to 10).”

      Read the research, not the medical column rehash that is often not up to date with the best data. That said, everyone reacts slightly differently to medications – this is why you need to monitor the vitals of EVERYONE taking this Protocol.

  2. 1) My understanding is that the Army uses meloxicam (Mobic) with Tylenol in its IFAK kit because they don’t promote bleeding the way other NSAIDs do:


    http://www.usaisr.amedd.army.mil/pdfs/TCCCGuidelinesforMedicalPersonnel170131Final.pdf (scroll down to para 10 )

    Unfortunately, Mobic requires a prescription, although a doctor might be willing to give one since it is unlikely to be scanned by government regulators the way opoids are.

    2) For medical problems other than wounds, bleeding might be less of a concern.

    1. Caution: If you are prone to fluid retention, Mobic (Meloxicam) can cause and/or exacerbate fluid retention (Pitting Edema) in the lower extremities.

      Be sure to elevate the feet if this happens and weigh the pros and cons before continuing the dosage.

  3. Thanks for the article. The NOLS Wilderness Medicine folks include the 1,000mg acetaminophen/800mg ibuprofen dosage in their wilderness first aid training, so I got a bunch of those small pill dosage plastic ziplock baggies at my local drug store and put 2 x 500mg acetaminophen and 4 x 200 mg ibuprofen pills in each one, and put a couple of baggies in each of my first aid kits. I’ll go back and add a 100mg caffeine to each baggie. Just a suggestion – I also include a package of adult-dose aspirin in every kit for potential heart attack scenarios.

  4. Good article. Puts somethings in context and offers some good advice.

    I would warn people about two things. Pain medications like oxycodone are under attack because 60,000 or so people die each year by abusing drugs. First of all most of those deaths are the result of either fentanyl use OR gross misuse of prescription drugs like oxycodone and it’s variations. For many the goal is to reduce and perhaps eliminate your access to effective pain drugs and they are misrepresenting these drug deaths to do just that. If you undergo a serious operation you will be so happy that they have effective pain killing drugs available to help you. Do let them take these away from doctors by restricting the doctors ability to prescribe them.

    Oxycodone does not jump out of the bottle and “hook” you one opioids. This is scare talk. You MUST abuse them to get hooked on them. ALL the people who took opioids and died were NOT following a prescription to “take one every 6 hours as needed for pain”. In fact in most cases they were crushing multiple pills and consuming them in every imaginable way. I have a bottle of oxycodone on my bureau, it has sat there for almost three years now, and not once has it begged me to take some.

    One last point; for years the most dangerous drugs sold in drugstores were aspirin and tylenol. These drugs killed a lot of people. Most of those deaths were not the result of intentional misuse of the drug but more the result of innocent overuse. (I say “innocent overuse” because there is no high from taking 6 aspirin or tylenol and usually when people over use these drugs they do so to relieve pain and are unaware that these drugs can be harmful if used to excess.)

    I can guarantee you that if you consume 50 tylenol that you will be dead in a week or two from liver failure. Similar results from aspirin overdose. The bottom line is be careful with all drugs; prescribed and over the counter. But also be careful about those who would like to remove/restrict opioids from the doctors control.

    1. As a former prescription pain user I agree with everything you said. I have been on high doses of rx pain medications for many years. Now, I am on a tiny dose. All of the pain management doctors are now refusing to treat me. Everyone is running scared of the government. I went from 100MCG of Fentanyl patch to 12 MCG. I used to live a pretty normal life, now, I spend a lot of time in bed because the pain is overwhelming. I hope for all of us that truly need our pain medications that the government will make some changes to their restrictions. As a side note, my insurance company has raised all of my co-pays for narcotic pain relievers. It just seems fair that I pay more to get less???

    2. Bravo OneGuy. The “opioid crisis” is being blown all out of proportion and is far more related to illegally obtained drugs than to prescribed medications. Sure, pain is a natural process (so is death) and it’s very useful to identify where there is a problem. But excruciating chronic pain serves no good end. We have a moral obligation to try to assist people who are suffering in this way.

  5. For someone who is a self professed “not a medical anything”, ShepherdFarmerGeek is giving inaccurate medical advice!! I concur with Nurse Kim’s statement. One NEVER gives ibuprofen to anyone initially with a traumatic injury. It will amplify bleeding. Furthermore, as a physician with over 34 years of real world experience that has treated many individuals with “moderate” pain and as one who personally has had moderate to severe pain, I can attest to the lack of efficacy of the combination of acetaminophen and ibuprofen for “moderate pain”. Or perhaps it is all in how “moderate pain” is defined. Pain is a very subjective issue, despite the attempts to define it on a scale. It is not as “cut and dry” as the scales would lead one to believe. One person’s “moderate” is not another’s “moderate” despite attempts to standardize it. As to the “Pain Pack” reference, the web site promoted has several flaws when generalized to the entire scope of pain. If one looks at the “Next Generation Combat Medic” reference, the drugs that are promoted do not include Acetaminophen but rather uses IV Hydrocortisone, Ibuprofen, possibly Paracetamol and IV or IM Ketamine. These are hardly available in the bush and beyond the average individual’s ability to self administer them. Furthermore, if one does take the aforementioned “Pain Pack” combination, there is no rational reason to delay the Ibuprofen for one hour. I am not arguing for the use of opioids where other drugs will suffice and also not arguing for merely biting on a stick; however, the “Pain Pack” idea for the purposes this article promotes are not entirely rational and potentially harmful. Note, even the article’s author endorses use of Canadian opioids in “Strategy # 2”.

    1. 1) ShepherdFarmerGeek is not giving medical advice — he is passing on info that might be helpful in circumstances where a doctor is not available. That is what this blog is about.

      2) The utility of acetaminophen and ibuprofen with coffee for moderate to even severe pain has been noted in several medical sources:


      An extract:
      “Opioids have been used for thousands of years in the treatment of pain and mental illness. Essentially everyone believes that opioids are powerful pain relievers. However, recent studies have shown that taking acetaminophen and ibuprofen together is actually more effective in treating pain. ”

      See also


      (Note: Lower rating -> more effective.
      Note: Paracetamol is another name for acetaminophen )

      3) As I noted in a prior post, the military’s TCCC guidelines use the NSAID Mobic with acetaminophen for mild to moderate pain in soldiers’ first aid pack, although they use the opioid fentanyl for more severe pain PROVIDED the soldier is not at significant risk of shock or respiratory distress. In the source I cited, the TCCC guidelines indicated that katamine would be used for severe pain if shock or respiratory distress was a threat.

      Obviously you don’t want to promote bleeding if the medical problem is a wound. But a dentist prescribed a strong dose of ibuprofen for me after dental surgery whereas in the past I had gotten tylenol with codeine. The ibuprofen worked — although my understanding is that prolonged use of stronger doses can damage the liver.

    2. Medical Onocologist,

      I was wondering what level of training is needed to start making educated decisions when it comes to medical issues like this and no MD/RN is available. I’ve been through basic “keep them alive” first aid training in the military (tourniquets, cpr, shock, evaluation, stopping blood loss) and I’m not in a position to become a nurse or MD (I’d be at retirement age by the time I finished).

      What I can do is invest money and time into maybe one serious class/certification, but probably not more than one. The options I see are: nonstandard civilian versions of the Army Combat Medic class, EMT , Wildernesses EMT and Paramedic courses.

      Can you recommend a baseline level of training?


    3. Bro, it’s not my advice. This is a pain treatment protocol that is widely used. If the victim is bleeding heavily and you haven’t been able to stop it or if they’re already hypovolemic you have bigger issues than pain control. Treating the pain is lower on the food chain than the lifesaving priorities.

      There are trade-offs with every single thing you do to/for a trauma victim. The PPP is just one tool in the toolbox. And having personally experienced excruciating pain I’ve gotta tell you I’m glad to have something helpful that I can use for myself and others when its appropriate.

    4. Acetaminophen is the same as paracetamol.

      I get migraines. Sometimes very bad migraines. Taking either acetaminophen (paracetamol) or ibuprofen alone doesn’t touch them. Taking the two together, sometimes with added caffeine, usually does the trick. Brand-name Excedrin is aspirin, acetaminophen, and caffeine together. I can’t take aspirin, so my doctor suggested I take the acetaminophen/ibuprofen/caffeine combination, instead.

      If that doesn’t work, then I have to resort to codeine or hydrocodone. I can’t take triptans. I hate taking codeine or hydrocodone because they make me itch.

  6. There is a otc product out there called Goody’s extra strength headache powders. It comes in folded paper packets. It contains 260 mg acetaminophen, 520 mg aspirin, 32.5 mg caffeine and 60 mg potassium. Not the dosages recommended in the article but pretty effective on more moderate pain

  7. Dr. Kathy had something similar in her book and taught in her classes.

    After a surgery that I was told I would be in “significant” pain I was given some pain meds. I decided to try the other route and used them for pain without any issues. I guess everyone’s definition of “pain” is different but it worked for me.

  8. I have tried the acetaminophen and ibuprofen combination and found 500 mg acetaminophen and 400 mg ibuprofen to provide much more effective pain relief than either alone. Higher dosages are more likely to cause nausea or gastrointestinal discomfort without much increase in pain relief. Diclofenac is a non-opiod/non-controlled nsaid pain reliever that is also a useful option. But, keep in mind that any nsaid may promote bleeding.


    But, if maximum mental alertness does not need to be maintained, vicodin (hydrocodone/acetaminophone) or percocet (oxycodone/acetaminophen) is more effective.

  9. Keep in mind that some prescription generic opioid painkillers are inexpensive. The cost of the office visit to get the prescription far exceeds the cost of the drug in most cases. For example, I recently filled a prescription for norco 10/325 (10 mg hydrocodone, 325 mg acetaminophen) at costco using the goodrx.com gold discount. Cost for 60 tablets was $12.55 Using the goodrx.com free non-gold discount, it would have been $16.74 at costco or safeway. This is not a copay, but rather the discounted self-pay price. Costco also has their own free prescription med discount program which provides even lower prices in some cases.


  10. I am two weeks into recovery from back surgery. L3-L4 fusion. The only pain meds used are Tylenol and a prescription nsaid. I did not want to use any opioids after surgery and God has been faithful to provide the relief.

  11. Thank you for an excellent article. Please allow me to add one caution. The combination drugs, Opioids: vicodin and percocet both contains tylenol or Acetaminophen. When you look at the directions and precautions for this drug Acetaminophen, there is a warning for the maximum daily safe dosage. Don’t forget to add in the amount of Acetaminophen contained in the combination opioid drugs to the total safe daily dosage. Also, keep in mind, that daily safe dosage reduces with advancing individuals age. It is generally recommended that persons of advancing years not exceed 1,000 mg Acetaminophen in 24 hours to prevent liver damage. In addition to increased bleeding with ibuprofen, again one must use caution and follow directions carefully as kidney failure is possible with too high a dosage and or long periods of use. Key word is caution. Again, thank you for a good article.

  12. You can also get OTC opioids in Mexico. In England, you can go to Boots Pharmacy and get Nurophen Plus, a combo of ibuprofen and codeine. (You have to get it directly from the pharmacist at the window.) Works like a charm, for short-term pain management.

  13. Respectfully, ShepherdFarmerGeek IS giving MEDICAL ADVICE despite being “not a medical anything”. The references given by Don Williams clearly have an agenda and are biased. Placebos have a documented efficacy for pain, but if they work then fantastic. So does acupuncture. Let’s not get into that issue. Sure, we are looking for blog information when a Physician is not available. Let’s not over react when incorrect information is presented.

    1. 1) A week or so ago, in a discussion of vaccines I noted my respect for peer-reviewed science over voodoo alternative medicine lacking any discipline. Although I noted that SOME folk medicine has a long history of effective treatments even when the scientific basis was not understood–e.g, foxglove for heart ailments, well before the effective ingredient –digitalis –was identified. The proof is in the FACTS.

      But that cuts both way. Last time I checked, the Journal of the American Medical Association carried some weight with doctors. From

      “Question Do any of 4 oral combination analgesics (3 with different opioids and 1 opioid-free) provide more effective reduction of moderate to severe acute extremity pain in the emergency department (ED)?

      Findings In this randomized clinical trial of 411 ED patients with acute extremity pain (mean score, 8.7 on the 11-point numerical rating scale), there was no significant difference in pain reduction at 2 hours. Mean pain scores decreased by 4.3 with ibuprofen and acetaminophen (paracetamol); 4.4 with oxycodone and acetaminophen; 3.5 with hydrocodone and acetaminophen; and 3.9 with codeine and acetaminophen.

      Meaning For adult ED patients with acute extremity pain, there were no clinically important differences in pain reduction at 2 hours with ibuprofen and acetaminophen or 3 different opioid and acetaminophen combination analgesics.”

  14. Since the efficacy of any pain relief medication is “subjective” relative to the patients pain threshold and the most effective among them are either illegal or strictly controlled (Big Money-Big Brother). The information given, taken with lots of water (and a grain of salt) along with a healthy dose of discretion, is likely to provide the patient as much relief possible. As much as one could expect without medical intervention (Paging Dr. FRN….) or a late night no knock from your friendly neighborhood constabulary…
    I would offer the same advice as I suffer from severe joint pain and swelling. I find that alternating / combining OTC’s provide the best results.

  15. Cannabis was listed in the US Pharmacopeia 1850-1941. Main indication was pain. The Squibb catalog of 1906 lists describes as anodyne (pain reliever), narcotic, sedative, hypnotic (induces sleep), and antispasmodic. Antidote: caffeine. The National Academy of Medicine in 2017 stated effective for chronic pain. The Randomized Clinical Trials used in the meta-analysis showed a 30% pain reduction compared to placebo. Fascinating articles on older medical use for pain in Dr Todd Mikuriya’s Medical Marijuana Papers (1839-1972) and recent book Cannabis Pharmacy. Approved in 29 states for severe pain; Schedule 1 N (non-narcotic) under current federal law with no currently accepted medical use. All above in public domain. Its in Sir Wm Osler’s textbooks of medicine 1992 to at least 1913 editions. See also My Medicine, a book by a federal marijuana cigarette patient since 11/82. He told the FDA in 1978, Cannabis enabled him to get off Dilaudid and other opioids.

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