Painkillers and NSAIDs

Painkillers and NSAIDs, are types of drugs called analgesics, which are used to treat pain.

The greatest difference is that painkillers target the levels of pain you’re feeling, by interrupting pain signals before they get to the brain.

NSAIDs, which can also be called non-steroidal anti-inflammatory drugs, help manage pain and fever, mostly by reducing inflammation.

However, if you have long term pain or inflammation, they are unlikely to improve the underlying problem that’s causing it.

Some painkillers and NSAIDs are available to buy from pharmacies, shops, or supermarkets. They are often recommended for managing mild to moderate pain yourself, over a short period of time.

These include:

• the painkiller - paracetamol
• NSAIDs – ibuprofen, aspirin, and diclofenac gel
• compound painkillers – co-codamol, paracetamol and ibuprofen, ibuprofen and codeine.

Your healthcare professional may also recommend using these drugs under their guidance over the long term, to help manage your condition.

Most people can use over-the-counter pain relief. However, some people may need to be cautious. Seek advice from a pharmacist or healthcare professional before taking them if you:

• are underweight
• are aged under 16, or over 65
• are pregnant or breastfeeding
• have lung problems, such as asthma
• have ever had fits or seizures
• have allergies
• have persistent headaches
• have problems with your liver or kidneys
• have had ulcers or bleeding in your stomach
• have had problems with your heart, liver, kidneys, blood pressure, or circulation
• are taking other medicines
• have had a stroke
• drink more than 14 units of alcohol a week
• have a condition affecting your connective tissue, such as lupus.

Painkillers containing codeine should only be taken for three days at most without medical advice. Taking other over-the-counter drugs for longer than ten days without guidance from a healthcare professional, could increase your risk of side effects such as problems with your stomach, heart, liver, or kidneys.

If over-the-counter drugs haven’t improved your pain your doctor may prescribe stronger pain medication or another type of treatment.

Risks and side effects

You should always check the manufacturer’s advice for guidance on ingredients and how much you can take over 24 hours.

Children, aged under 16, should not take aspirin unless it’s prescribed by a doctor, as it can cause an illness called Reye’s syndrome, which can damage the brain and liver, and could be fatal.

Paracetamol is used to reduce fever and can help manage mild to moderate aches and pain. You can take paracetamol as a tablet, capsule, liquid, or as tablets that dissolve in water. It should start working within the hour and last for around five hours.

Though paracetamol is safe for most people, your doctor may advise against using it if you have another health issue.

If you have problems such as lower back pain, or osteoarthritis, taking paracetamol alone may not be the most effective treatment.

You can take paracetamol with NSAIDs, such as ibuprofen or aspirin, or with another painkiller called codeine.

However, be careful if you’re taking medicines for migraines, coughs, colds and flu, or compound painkillers, because these drugs often already contain paracetamol.

Taking too much paracetamol can cause liver failure.

If paracetamol isn’t helping, a healthcare professional may recommend other treatments, such as a programme of exercise, physiotherapy, or a stronger type of pain relief.

NSAIDs, or non-steroidal anti-inflammatory drugs, are recommended for short-term relief from pain, fever, and swelling or stiffness around your bones and joints.

You should feel some relief within an hour of using NSAIDs, but it can take several days or weeks before you feel the full benefit.

If you’ve been using over-the-counter NSAIDs, such as ibuprofen or aspirin, your doctor may recommend you continue taking them under their guidance, before considering another treatment.

These drugs can cause side effects, particularly if you take them for a long period of time. You are likely to be prescribed a short course of an NSAID at the lowest possible dose to treat your pain.

There are around 20 NSAIDs that are commonly prescribed, these include:

• ibuprofen
• ketoprofen
• fenbufen
• piroxicam
• aspirin
• naproxen
• diclofenac
• indomethacin
• celecoxib
• etoricoxib.

They can be taken as either:

• tablets or capsules you swallow
• a liquid you drink
• a suppository, a medicine you place in your bottom
• a cream, gel, spray, plaster, or mousse you apply to the skin – known as topical NSAIDs.

Your doctor should discuss with you the type of NSAID that’s best for you, and they should arrange regular check-ups to review your progress.

NSAIDs may not be suitable for everyone. The type of NSAID you are prescribed may depend upon other health issues, such as if you:

• are over 65
• might be pregnant or you’re breastfeeding
• have asthma or allergies
• have had a reaction to an NSAID
• have had ulcers or bleeding in your stomach
• have had problems with your heart, liver, kidneys, blood pressure, or circulation
• are taking other medicines
• have had a stroke
• have problems with your stomach, intestines, or bowels such as ulcerative colitis or Crohn’s disease
• problems with your blood pressure, circulation, or bleeding
• have a condition affecting your connective tissue, such as lupus
• experience persistent headaches.

Depending on what’s causing your pain, your doctor may first recommend trying a topical NSAID, such as ibuprofen, ketoprofen, felbinac and piroxicam, as they may cause fewer side effects than tablets.

They are often recommended for treating isolated areas of pain and inflammation caused by osteoarthritis, particularly in the hands and knees.

Topical NSAIDs may not be helpful for people with inflammatory conditions, such as rheumatoid arthritis, because their pain is more widespread.

However, NSAIDs are considered the most effective way of relieving pain and inflammation caused by rheumatoid arthritis.

NSAIDs can cause stomach problems so your doctor is likely to prescribe a drug called a proton-pump inhibitor (PPI), such as omeprazole or lansoprazole, to reduce the amount of acid in your stomach.

Some NSAIDs, such as celecoxib, etoricoxib, are designed to be gentler on your stomach.

Depending on your condition, you may be prescribed other drugs, such as disease-modifying anti-rheumatic drugs (DMARDs) or steroids. These drugs can help reduce your pain by treating the condition that’s causing it.

You can use NSAIDs if you are taking paracetamol. However, you should be careful taking NSAIDs with compound painkillers because some compound painkillers contain NSAIDs.

If you have concerns about taking NSAIDs seek advice from a healthcare professional.

Risks and side effects

If you’re taking anti-coagulant drugs to thin your blood, such as low-dose aspirin or warfarin, you’re best to avoid taking other NSAIDs or compound painkillers.

Even at low doses NSAIDs can cause side effects, such as:

• headaches
• dizziness
• stomach pains, sickness, diarrhoea, and indigestion
• bleeding
• swollen ankles
• problems when you pee
• chest pains and difficulty breathing
• a rash or sensitivity to sunlight.

If you experience any side effects, stop taking the pain relief and speak to your doctor.

Long-term use of NSAIDs, can cause problems with the liver, kidney, heart, and blood circulation.

NSAIDs can cause stomach problems and are best taken with food or a drink of milk to help reduce these side effects.

If you’re aged over 65, some NSAIDs can increase your risk of developing stomach ulcers. If you’re at risk of developing stomach problems or you get stomach pains after you’ve taken your NSAIDs, speak to your doctor.

NSAIDs can cause side effects and their long-term use should be monitored by a healthcare professional.

Compound painkillers combine two types of pain relief medication.

Some compound painkillers are available over the counter from a pharmacist, others can only be prescribed by a healthcare professional.

For example:

• co-codamol containing low-dose codeine and paracetamol, available over the counter
• paracetamol and ibuprofen tablets, available over the counter
• ibuprofen and codeine, available over the counter
• co-dydramol containing paracetamol and dihydrocodeine, available on prescription
• co-codaprin containing codeine and aspirin, available on prescription.

Depending on what is causing your pain, your doctor is likely to recommend you try paracetamol and NSAIDs, before prescribing compound painkillers.

Compound painkillers can be taken as tablets, capsules or dissolved in water.

Healthcare professionals are unlikely to prescribe compound painkillers containing the opioids codeine and dihydrocodeine for longer than a few days, because there’s little evidence that they help long-term pain.

Talk to your doctor if you’re taking compound painkillers but you’re still in pain.

To avoid accidentally taking too much of any drugs, make sure you know what your compound painkiller contains and avoid these ingredients while you’re taking it.

Because each of the ingredients can cause different side effects, compound painkillers may increase your risk of an unpleasant reaction.

Risks and side effects

Compound painkillers can reduce your pain, but they may cause more side effects.

Compound painkillers containing aspirin, paracetamol, or ibuprofen, carry the same risk of side effects as taking these drugs separately.

Common side effects of compound painkillers include:

• feeling sick
• drowsiness
• feeling dizzy
• heartburn or indigestion
• constipation.

People who take painkillers containing opioids can become dependent on them if they take them for a long period of time.

Ask your doctor’s advice before using compound painkillers if you’re pregnant or breastfeeding.

Low dose antidepressants can be prescribed to treat long term, persistent pain.

These drugs were originally developed to treat anxiety and depression. However, when taken at a lower dose they have been found to effectively treat pain. Doctors are now being encouraged to prescribe low dose antidepressants before other pain relief treatments.

If you are prescribed antidepressants, they can improve the way your body responds to pain, your mood, emotional state, and sleep quality.

Antidepressants commonly recommended for pain include:

• amitriptyline
• citalopram
• duloxetine
• fluoxetine
• paroxetine
• sertraline.

These drugs may not be suitable for everyone. Because they weren’t originally designed to treat pain, your doctor may first want to discuss the benefits and risks of prescribing them, before deciding whether an antidepressant would help your condition.

Antidepressants can affect other conditions, including:

• diabetes
• epilepsy
• heart problems
• glaucoma
• overactive thyroid gland
• severe liver disease.

Risks and side effects

Many people take antidepressants without experiencing any problems, but they can cause some side effects. Many of the more common ones go once your body gets used to them.

Side effects include:

• constipation
• dizziness
• dry mouth
• feeling sleepy
• blurred eyesight
• difficulty peeing
• headache.

If these side effects don’t improve speak to your doctor or pharmacist.

Occasionally people can experience weakness down one side of their body, or trouble speaking, thinking, or balancing. If you experience these side effects seek urgent medical advice.

Some people also experience changes in their appetite and weight when they start taking antidepressants, if this concerns you speak to your doctor.

Some antidepressants can make you drowsy. You’re advised to avoid cycling, driving, or using machinery for the first few days of taking them, until you know how they affect you.

Nefopam is a non-opioid painkiller that can be prescribed to treat pain, if NSAIDs and paracetamol have not helped.

It causes fewer breathing problems than opioid drugs. It can sometimes be prescribed as an extra way of managing your pain with paracetamol, or NSAIDs such as ibuprofen or naproxen.

However, it has not been shown to be hugely beneficial to people with long term pain and can cause several side effects.

Risks and side effects

Nefopam can cause side effects including:

• nausea
• nervousness
• confusion or seeing things that aren’t there
• numbness and tingling in your hands or feet
• problems when you pee
• dry mouth
• light-headedness.

You may not be able to take nefopam if you:

• are epileptic or have ever had seizures
• have liver or kidney problems
• have problems peeing
• have angle closure glaucoma.

If you are aged over 65 you may be more likely to feel confused or to see things that aren’t there. Nefopam is not usually recommended during pregnancy.

Opioid painkillers can be prescribed to offer relief from moderate to severe pain when other forms of pain relief haven’t worked.

Some opioids are stronger than others. If your doctor feels your pain can only be helped by opioids they will prescribe the lowest dose, for the shortest time. Opioids are available as tablets, liquids, or patches.

However, because of the risk of side effects such as addiction and overdose, healthcare professionals are advised to avoid prescribing opioid painkillers for long-term pain, where possible. If you are prescribed opioid painkillers your treatment should be strictly monitored.

If you think your pain medicines aren't helping with your symptoms, or are causing unpleasant side effects, it might be a good idea to reduce or stop them. Discuss with your doctor how to minimise the risk of any withdrawal symptoms. This could include gradually reducing the dose, and having regular reviews with your healthcare team.

Opioid painkillers include:

• codeine
• dihydrocodeine
• tramadol
• buprenorphine
• fentanyl
• morphine
• diamorphine
• oxycodone
• tapentadol.

The low-dose codeine used in compound painkillers is the only opioid painkiller available without a prescription.

Opioid patches

Your doctor may consider prescribing you a course of treatment with opioid patches if you’ve tried a low-dose opioid, such as morphine, and you’re still in pain.

These patches usually contain either buprenorphine or fentanyl, which is slowly released into the body over a period of several days. For guidance on how often you should change your patch, see the patient information leaflet included in the pack.

You should only wear one patch at a time, unless told otherwise by your doctor.

You should keep the area the patch is stuck to away from any source of heat, such as a hot water bottle, electric blanket or heat pads, or sunlight. This is because heat can cause too much of the drug to be released into the blood stream too quickly.

You should inform any healthcare professional treating you that you are using opioid patches, as they can interact with other drugs.

Risks and side effects

Opioid painkillers commonly cause more side effects than other pain treatments and they need to be strictly monitored by your doctor.

Risks and side effects of opioid painkillers include:

• feeling or being sick
• problems going to the toilet
• itching
• drowsiness and dizziness
• not being able to concentrate
• low sex drive, reduced fertility, and erectile dysfunction
• more difficulty fighting off infections
• increased pain
• breathing problems.

Some side effects will lessen over the course of treatment. If you are concerned speak to your doctor.

If you have breathing problems, such as sleep apnoea, asthma, or chronic obstructive pulmonary disease (COPD), speak to your doctor before taking opioid painkillers.

Taking opioids with sedative drugs, such as diazepam, temazepam, or alcohol, can make you more likely to feel drowsy, dizzy, and unable to concentrate.

Opioid drugs can cause seizures. If you are taking antipsychotic or antidepressant drugs you could be more likely to experience seizures if you are prescribed the opioid drug tapentadol.

Opioid painkillers can become addictive and should be used with caution. Speak to your doctor if you feel they aren’t working at the prescribed dose, or you are still in pain after finishing a course of opioid painkillers.

Your doctor may recommend you stop taking opioids. Depending on how long you have been taking them you may experience some reactions, including:

• tremors or muscle spasms
• anxiety, sweating, or restlessness
• sickness, diarrhoea, or stomach cramps.

If you have been taking opioid painkillers for a long period of time you should only stop taking them under the guidance of a healthcare professional, as suddenly stopping your treatment can be dangerous.

Many people with arthritis and related conditions will need to take painkillers or NSAIDs, along with drugs that treat the underlying cause of their condition. The combination you take and the length of time you take them for will depend on your condition.

For inflammatory types of arthritis, such as rheumatoid arthritis, your doctors should recommend starting treatment with a disease-modifying anti-rheumatic drug (DMARD), such as methotrexate.

DMARDs won’t stop your pain straight away, but once they start to work, you should be able to reduce or stop your pain relief drugs.

If you have gout, you may be prescribed the anti-inflammatory drug colchicine or an NSAID to deal with the pain and swelling from an attack. Aspirin may make your gout worse. You may need to take another drug, such as allopurinol or febuxostat, in the longer term to reduce the risk of having more gout attacks.

If you have osteoarthritis of the hand or knee, you can use capsaicin cream to treat the affected joints several times a day, as well as taking painkillers.

If you’re taking medications for other conditions, you should speak to your doctor or a pharmacist about possible interactions.

Complementary treatments

Complementary treatments, such as herbal remedies, vitamins, and supplements, are not tested the same way as painkillers and NSAIDs, so it’s difficult to say whether they are safe to take together.

You should always tell the healthcare professional treating you about any other medications you are taking, including complementary treatments, herbal remedies, vitamins, or supplements, before you start your prescribed medication.

Most people who take painkillers or NSAIDs can drink alcohol in moderation.

Alcohol can increase the risk of side effects of some painkillers and NSAIDs. It’s a good idea to read the leaflet that comes with your drug to see what it says about drinking alcohol.

If you’ve just started taking opioid painkillers, or your dose is increased, you’re advised to avoid drinking alcohol until you’ve settled on your medication. Alcohol and opioid painkillers can affect your concentration and can make you sleepy.

You’re advised to avoid alcohol if you’re driving or using machinery.

It’s best to stick within government guidelines of drinking no more than 14 units of alcohol per week, and to spread the units through the week. Having two or three days each week when you don’t drink alcohol is good for you.

Talk to your doctor or a pharmacist if you have any concerns.

If you’re planning to start a family or you become pregnant, you should discuss your medication with your doctor as soon as possible.

Paracetamol is usually the recommended pain relief option if you’re pregnant or breastfeeding, but it’s a good idea to talk to your healthcare professional about any medications.

NSAIDs are not usually recommended in pregnancy, especially after 30 weeks, unless you’re advised to take them by your doctor.

In rare cases low-dose aspirin may be continued during pregnancy but only under specialist care for severe conditions, including:

• high blood pressure
• certain other long-term conditions - such as lupus.

NSAIDs are considered safe to take if you are breastfeeding.

Low dose antidepressants are considered safe during pregnancy.

Paracetamol and opioid painkillers may be used during pregnancy, although it is recommended that you do not use them regularly or for long periods.

Taking opioids in pregnancy can increase the risk of your baby having breathing problems, experiencing painful effects from withdrawal, and may affect their brain function in future. They should only be taken under the guidance of a doctor.

Some low doses of opioids, such as dihydrocodeine, are considered safe if you’re breastfeeding, but you should avoid anything containing codeine.

If you’re a pregnant woman who has been taking opioids every day for a while, you shouldn’t suddenly stop using them without speaking to your doctor.

Stopping opioids without help from your doctor or midwife can be dangerous for yourself and your child, particularly in your first trimester when it can cause miscarriage, and the last trimester when it can increase the risk of birth complications and stillbirth.