Which Medicine Is Best for Pain: Percocet, Vicodin, or Tylenol #3?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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You’ve had surgery, you have a toothache, or you can’t move without severe back pain and Tylenol (acetaminophen) and ibuprofen aren’t helping. What’s next?

Conventionally, patients who have moderate to severe pain have been offered one of the opioid-nonopioid combination drugs, such as acetaminophen plus hydrocodone or oxycodone.

Are they the same? What’s better? What is the prescription I have? It seems complicated but it’s not—let’s shed light on the common players:

Acetaminophen + Codeine:

You may have been prescribed Tylenol #3 or Tylenol #4 in the past. Both have 300 mg of acetaminophen mixed with either 30 mg of codeine or 60 mg of codeine (in the Tylenol #4). While really good for short-term pain—evidence shows that it’s just as good as acetaminophen + hydrocodone—codeine is not recommended for chronic pain management. This is because adverse effects increase disproportionately to analgesic (pain relieving) effects. Get that: long term use of Tylenol #3 is not really recommended because increased doses result in increased side effects. Short term, it’s a great choice.

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Acetaminophen + Hydrocodone:

Familiar options in this class include Vicodin, Lorcet, Lortab, Norco and Zydone. Interestingly, short-acting hydrocodone is only available mixed with acetaminophen or ibuprofen in the United States. This group of meds comes in many doses, with the hydrocodone part ranging from 2.5 mg to 10 mg now mixed with lower doses of acetaminophen, usually 300 mg. You’ll remember this was an FDA recommendation because of acetaminophen overdoses in people on these pain meds. A brand new long-acting hydrocodone (without acetaminophen) was just approved and it’s called Zohydro ER. Zohydro ER is taken 10 mg orally every 12 hours. For pain that is going to be short lived, like postoperative pain, you don’t really need a longer-acting medication like Zohydro. Studies comparing Tylenol #3 with Vicodin indicate they both work the same for pain.

Acetaminophen + Oxycodone:

Percocet or Roxicet are the brand names in this class. When acetaminophen + oxycodone is used the usual starting dose is 5 mg of oxycodone. Percocet has at most 10 mg of oxycodone in it, as a 10 mg / 325 mg tablet mixed with acetaminophen. Oxycodone is available alone or mixed with acetaminophen or ibuprofen. Oxycodone tablets come as a generic or the brand name Roxicodone. Oxycontin, a popular drug of abuse, is oxycodone that is slow release. Roxicodone comes in 5 mg, 15 mg, and 30 mg tablets while Oxycontin comes in much higher doses of oxycodone.

For short-term use, long-acting formulations like Oxycontin usually aren’t needed.

Also not included in this list are newer mixed mechanism analgesics like Ultram (tramadol) or Nucynta (tapentadol). Those are the so-called “non-opiate opiates,” so they work on the opiate receptors but are not the same as the above-listed drugs.

There it is . . . pain meds 101.

Dr O.

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