Most pain regimens start with acetaminophen (brand name: Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID, pronounced EN-sed). Mild but persistent discomfort, such as breast and underarm surgery pain, can usually be managed by these medications alone.

There are many NSAIDs, including:

• ibuprofen (brand names: Advil, Motrin, Nuprin)
• naproxen (brand names: Naprosyn, Naprolan)
• naproxen sodium (brand names: Aleve, Anaprox)
• ketoprofen (brand name: Orudis)
• indomethacin (brand name: Indocin)
• piroxicam (brand name: Feldene)
• nabumetone (brand name: Relafen)

The response to NSAIDs varies from person to person and medication to medication. If pain doesn't lessen or end when you use one NSAID, that doesn't mean it won't improve if you try another.

You may need to try different NSAIDs before finding the right one for your pain. Never take more than the maximum dose recommended by the manufacturer. If you're taking aspirin, Coumadin (chemical name: warfarin), or other blood thinners, or if you have kidney problems, talk to your doctor BEFORE adding, changing, or increasing your dose of NSAIDs.

NSAIDs can cause upset stomach, heartburn, water retention, stomach ulcers, and thinning of the blood. All NSAIDs can decrease kidney function, which your doctor can monitor with routine blood tests.

Although the drugs known as COX-2s (Celebrex, Vioxx, and Bextra) do not cause blood thinning and are easier on the stomach, they have recently come under heavy fire because of new clinical trials showing increased risk of heart attack and stroke, and Vioxx is no longer on the market.

If NSAIDs are unable to control all your pain, the next level of treatment adds an opioid (pronounced OH-pee-oyd) to the NSAID. Opioids are also called narcotics and include such drugs as morphine or codeine.

Because of the way the medications work, a combination dose of an NSAID and an opioid may provide more pain relief with fewer side effects than an opioid alone. There are many good NSAID/opioid combinations.

Why not simply increase the amount of NSAIDs you're taking instead of adding an opioid? The reason: NSAID dosages have an upper limit. Too much can cause kidney and liver damage, or worse. Opioids may be given in increasing doses without a comparable risk. Side effects from opioids may be a problem, but most are treatable.