Painkillers Analgesics

7/21/2019 Painkillers Analgesics

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Drug informationPainkillers

Painkillers(analgesics)This leaflet provides information on painkillersand will answer any questions you have aboutthe treatment.

Arthritis Research UK produce

and print our booklets entirely

from charitable donations.


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Although everyone understandswhat we mean by the wordpain, its still difficult to define.

Put simply, its usually a protectivemechanism that alerts your brainwhen damage has occurred. Painis unpleasant, but its often short-lived and the reasons for it are

usually easy to understand, forexample if youve had a fall orburnt yourself. You may decideto take painkillers to ease the painuntil it gets better, and if you have

arthritis or a related condition youmay want to take them duringflare-ups. You can also take thembefore you exercise to helpprevent pain.

What is pain?


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Arthritis Research UKPainkillers

Whats inside?

2 What are painkillers?

2 Simple non-opioid analgesics Paracetamol

Non-steroidal anti-inflammatory

drugs (NSAIDs)

Aspirin

Ibuprofen

5 Compound analgesics

Table 2:Common examplesof compound analgesics

7 Opioid analgesics

Table 3:Common examples

of opioid analgesics

10 What other drugs can helpease pain?

Disease-modifyinganti-rheumatic drugs (DMARDs)

and biological therapies

Steroids

10 Which medications can helpwith osteoarthritis?

11 Which medications can help

with inflammatory arthritis?11 What medications are used

in nerve (neuropathic) pain? Amitriptyline

Gabapentin and pregabalin

12 What if I have problemswith my heart?

12 Where can I get moreinformation?


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What are painkillers?Painkillers are drugs that help to reducepain. When we talk about painkillers, wereusually referring to a group of drugs calledanalgesics. There are three different typesof analgesics, as shown in Table 1.

Drugs may be available under severaldifferent names. Each drug has anapproved (or generic) name but

manufacturers often give their own brandor trade name to the drug as well. Forexample, Nurofen and Panadol are brandnames for ibuprofen and paracetamol,which are the approved names.

The approved name should always beon the pharmacists label even if a brandname appears on the packaging, but checkwith your doctor, nurse or pharmacist if

youre in any doubt. Well use the approvednames in the sections that follow.

You dont need to wait until your pain issevere to use analgesics. Take them as thepacket advises or as your doctor suggests.Many people find that analgesics arentas effective as they could be becausethey dont take them correctly.

Simple non-opioidanalgesicsSimple non-opioid analgesics are themost common type of analgesic. Themost common of these is paracetamol.

ParacetamolParacetamol is available over the counterand is widely used as a painkiller for mild

to moderate pain, for example followinga minor injury, and for headaches andmuscular pains. Paracetamol will alsoreduce a fever. Its available in 500 mgtablets or in liquid form for children.Its usually taken in doses of two 500 mgtablets up to four times a day. Its welltolerated with very few side-effects.Some people develop a rash, but this

is very rare.

At doses higher than 4,000 mg(eight tablets) per day, paracetamol canseriously damage your liver. The numberyou can buy at any one time is limitedbecause of this risk. Care must be takenif you have liver problems or drink a lotof alcohol. It must also be used in lower

doses if you have kidney problems.Be aware that many other products,for example cold and flu medications,contain paracetamol.

Paracetamol is well tolerated duringpregnancy or breastfeeding as longas its not taken regularly or in dosesof more than 2,000 mg per day.

You can take

analgesics beforeexercise to helpprevent pain.

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TYPE

Simple non-opioidanalgesicse.g. paracetamol, aspirin,

ibuprofen

Compound analgesicse.g. co-codamol, co-codaprin,

co-dydramol

Opioid analgesicse.g. codeine, tramadol,

morphine

What arethey?

The most commonform of analgesic, alsoincluding non-steroidalanti-inflammatorydrugs (NSAIDs)

A combination of drugsin one tablet, usuallyincluding paracetamol,aspirin and codeine

The strongest typesof painkiller

What are

they usedfor?

Mild to moderate

pain, for exampleheadaches, injuriesand osteoarthritis,or as an addition tostronger painkillers

Mild to moderate pain,

for example injuries andosteoarthritis, or as anaddition to NSAIDs

Moderate to severe pain

caused by osteoarthritis,or as an addition toNSAIDs for severe pain

Where do Iget them?

Over the counter atsupermarkets andchemists, although someNSAIDs are only availableon prescription

Milder forms are availableover the counter, butstronger types are onlyavailable on prescription

Only availableon prescription

What arethe commonside-effects?

Paracetamol hasfew side-effects buthigh doses can causeliver damage

NSAIDs have moreside-effects, particularlyon the stomach

Compounds madefrom codeine can causeconstipation, nausea andloss of concentration

Nausea and vomiting,constipation, drowsinessand dizziness

What else

shouldI know?

Shouldnt be used at high

doses for long-term pain

Paracetamol and someNSAIDs are availableas suppositories

Can be used instead of

NSAIDs if these cant betaken for any reason

Can cause more side-

effects compared withnon-opioid types

Table 1 Common examples of analgesics

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PAIN LEVEL

SevereMild Moderate


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Paracetamol doesnt have an anti-inflammatory effect, which means its less

helpful for inflammatory arthritis, suchas rheumatoid arthritis, so its commonlytaken in combination with non-steroidalanti-inflammatory drugs (NSAIDs). Itsusually the first treatment recommendedfor easing pain caused by osteoarthritis.

Non-steroidal anti-inflammatorydrugs (NSAIDs)NSAIDs are a type of simple non-opioid analgesic. They help to reduceinflammation, which reduces pain.

They can be used in combination withother simple or compound analgesics,so they can be helpful even whentheres not a great deal of inflammation,for example in osteoarthritis.

NSAIDs start working within a fewhours. The effects of some will only lastfor a few hours but others are effective

all day. Your doctor will help you to

find the best formula and dose for you.There are now about 20 different NSAIDsavailable, the most common being aspirinand ibuprofen.

AspirinAspirin is widely used as a painkiller formild to moderate pain. It can reducefever and has an anti-inflammatory effect.

Its available over the counter in 300 mgtablets and is usually taken in doses of300600 mg four times a day after food.

Aspirin can cause stomach-relatedside-effects at higher doses. Solubleforms reduce this risk to some extent,as do enteric-coated tablets (which havea coating to make sure the drug isnt

absorbed into the body until it reachesthe small intestine), but you shouldnttake it if you have indigestion, heartburnor a history of stomach ulcers. It cancause serious bleeding in the digestivesystem, particularly if you drink alcohol,take the blood-thinning drug warfarin orare over 60. For this reason many doctorswill now advise you to take some of the

newer NSAIDs such as ibuprofen for painrelief because of the reduced risk of side-effects. You shouldnt use fish oil if youretaking aspirin because they can interact.

Aspirin can also make asthma worse andcan cause an allergic reaction that resultsin rashes and hives. If you experience anyof these side-effects you must stop takingaspirin immediately. Children and youngpeople under the age of 16 shouldnttake aspirin.

Many differentNSAIDs areavailable, so if onedoesnt work youcan try others.


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Compoundanalgesics combinetwo different

drugs. Theyreused for mild tomoderate pain.

Aspirin is also used in low doses (75 mg

daily) to reduce the risk of strokes andheart attacks. This dose doesnt havea pain-relieving effect. If youre onlong-term, low-dose aspirin you mustbe careful about taking other NSAIDsbecause it increases the risk of stomachbleeding. Ask your doctors advice ifyoure unsure.

IbuprofenIbuprofen is a widely used painkiller andanti-inflammatory. Its available over thecounter in doses of 200400 mg andcan be taken up to four times a day afterfood. You can also use ibuprofen gels andcreams, which you rub directly onto theaffected area.

Stronger and slow-release NSAIDs areavailable on prescription and can be usedfor rheumatoid arthritis and other typesof inflammatory arthritis. You shouldnttake more than one NSAID at a time.

NSAIDs can have serious side-effects andshouldnt be used long-term. Speak toyour doctor if you need longer termpain relief.

For more information see Arthritis

Research UK drug leaflet

Non-steroidal anti-inflammatory drugs.

Compound analgesicsCompound analgesics are made froma combination of two different drugs.

The most commonly used drugs incompound analgesics are:

paracetamol

aspirin

codeine

dihydrocodeine.These drugs are most commonly usedbecause they cause fewer, less severeside-effects. Some compound analgesicscontaining low doses of codeine areavailable over the counter, but otherstronger ones are only available onprescription. Ask your doctors adviceif youre pregnant or breastfeeding.Older people may be advised to reducethe maximum dose.

Common examples of compoundanalgesics are listed on the next page(see Table 2).


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TYPE

Co-codamol Co-codaprin Co-dydramol

What is it? Codeine (8 mg) andparacetamol (500 mg)

Codeine (8 mg) andaspirin (400 mg)

Dihydrocodeine (10 mg)and paracetamol(500 mg)

What dosecan I take?

Up to two tablets fourtimes a day

Up to two tablets fourtimes a day with food

Up to two tablets fourtimes a day

Where do

I get them?

Over the counter or on

prescription

On prescription On prescription

What arethe mostcommonside effects?

Constipation, nausea,drowsiness and dizziness

Constipation, nausea,drowsiness, dizziness,heartburn andindigestion

Constipation, nausea,drowsiness and dizziness

What elseshouldI know?

For more severe pain,combinations of15 mg/500 mg and30 mg/500 mgare available

For more severe pain,combinations of20 mg/500 mg and30 mg/500 mgare available

Table 2 Common examples of compound analgesics

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Opioid analgesicsOpioid analgesics can be more effectivefor pain relief than simple non-opioidanalgesics, so theyre used for moderateto severe pain. Pain is considered to besevere if its disabling, meaning you haveto take more frequent rests or can onlywalk or move awkwardly.

Opioid analgesics can cause more side-

effects than simple analgesics and can leadto dependency and addiction, so theyreonly available on prescription and youllbe monitored more closely by your doctor.

Theyre only used if other analgesicshavent worked. In many cases theyreused for short periods of time or alongsideother painkillers when necessary to reducethe risk of side-effects and dependency.

All side-effects are more common in olderpeople, so the dose may be reduced.

The most common side-effects withopioid painkillers are:

nausea and vomiting (some people are

more prone to this than others but it

often settles with time)

constipation

drowsiness and dizziness, which is

increased when combined with alcohol

be careful when driving and using

electrical equipment

reduced concentration or confusion

reduced ability to breath (respiratorydepression) make sure the doctor

prescribing the drug knows if you have

long-term breathing problems like

chronic obstructive pulmonary disease

or asthma.

If you experience any side-effects, talkto your doctor.

Opioid analgesics come in a tablet orpatch. Your doctor will advise on whichtype is best for you depending or theseverity of your pain, your age and anyother medication that youre taking(see Table 3).

Opioid analgesicsare reservedfor moderateto severe pain.


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TYPE

Codeine anddihydrocodeine

Tramadol Buprenorphine

What are they? The most widelyused weakopioid analgesics

Stronger than codeineand dihydrocodeineand may work in aslightly different way

A strong opioidanalgesic for severepain but can also begiven at a low startingdose when used as alow-dose patch

What dosecan I take?

3060 mg up to fourtimes a day

50100 mg up to fourtimes a day

Available in slow-release patches,which have differentstrengths and can lasta week

What are theside-effects?

Constipation, nausea,drowsiness anddizziness so areavoided for long-termuse whenever possible

Fewer side-effectsthan other opioids,but makes somepeople feel veryfuzzy-headedor confused

Constipation, nausea,drowsiness anddizziness avoidedfor long-term usewhenever possible

Patches may causean allergic reactionwhere theyre appliedto the skin

What else shouldI know?

Available at variousstrengths and in slow-release formulas forlong-term pain

Available in aslow-release formulaof 100200 mg forsevere pain

Can also be combinedwith paracetamol,which increases itseffectiveness

Also comes in atablet which is placedunder the tonguefor an immediatepainkilling effect

Table 3 Common examples of Opioid analgesics

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TYPE

Fentanyl Morphine Oxycodone Methadone

A strong opioidanalgesic used forsevere, long-term pain

A strong opioidanalgesic used aftersurgery and for severe,long-term pain

A strong opioidoccasionally usedfor severe pain andcancer pain

A long-actingand strong opioid

Prescribed as a patchwhich is applied to theskin every 3 days

Available in slow-release tablets (MST),which are usuallytaken twice a day

Available in a varietyof strengths astablets or as slow-release tablets

Dose varies accordingto the severity ofthe pain

Can causeconstipation,nausea, drowsinessand dizziness

Patches may causean allergic reactionwhere theyre appliedto the skin

Often causesnausea and vomitingas well as constipation,drowsiness anddizziness

Often causes nauseaand vomiting,constipation,drowsiness anddizziness

Often causes nauseaand vomiting,constipation,drowsiness anddizziness

Also available inlozenge form forimmediate pain relief

Also availableas a liquid and asuppository, or aninjection for verysevere pain

Less sedating thanmorphine

usually taken twicea day to reduce side-effects when usedlong term

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What other drugscan help ease pain?A number of other drugs that work indifferent ways to analgesics also helpto reduce pain. These include disease-modifying anti-rheumatic drugs(DMARDs) and steroids.

Disease-modifying anti-rheumaticdrugs (DMARDs) and biologicaltherapiesDMARDs (which include traditionalDMARDs, immunosuppressant DMARDsand biological therapies) are only usedif youve been diagnosed with a specifictype of arthritis, for example rheumatoid

arthritis, and theyre only available onprescription. They work by altering theunderlying disease rather than treating

the symptoms. Theyre not painkillers, but

theyll reduce pain, swelling and stiffnessover a period of weeks or months byslowing down the disease and its effectson the joints. It can take months beforethey take effect, but theyre very useful foreasing pain once theyve started to work.

SteroidsLike DMARDs, steroids are only

used for certain types of arthritis,including rheumatoid arthritis, lupusand polymyalgia rheumatica (PMR).

They help to reduce inflammation,which can ease pain.

Steroids can be given in tablet form oras an injection. Steroid injections may beoffered to people with osteoarthritis if

they have inflammation in their affectedjoints. Both injections and tablets workvery quickly, although they wont cureyour condition.

Which medications canhelp with osteoarthritis?If you have osteoarthritis youll probably

experience pain at times, so you shoulduse painkillers when its interfering withyour everyday life. Some people withosteoarthritis will find that the painis more constant, making day-to-dayactivities difficult, affecting concentrationand disturbing sleep. If your pain affectsyou in these ways you may need to takecombinations of medications.

Taking combinations can also often helpif you have back or neck pain.

Depending on whattype of arthritis youhave, your doctormay prescribe specific

drugs for your pain.


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Which medicationscan help withinflammatory arthritis?If you have inflammatory arthritis, suchas rheumatoid or psoriatic arthritis, youllneed to take a combination of drugs.NSAIDs are more effective than analgesicsin relieving the pain and stiffness ofinflammatory arthritis. You may also

be prescribed one or more DMARDs suchas methotrexate and biological therapiesby a rheumatologist. These drugs easepain, swelling and stiffness, and reducethe risk of longer term damage to the

joints. Once the DMARDs start to workyou may not need to take analgesics andNSAIDs as often.

Other types of arthritis also cause painbut require treatments that are morespecific, for example NSAIDs are veryeffective in gout whereas analgesicsarent. You should speak to your doctorif youre unsure.

What medications

are used in nerve(neuropathic) pain?Nerve pain can be caused by damageto nerves or nerve endings. This causesthe nerves to send pain signals to thespinal cord spontaneously, withoutneeding a specific stimulus, or in responseto something that wouldnt normally

hurt, such as gentle stroking of the skin.This sometimes happens in complicationsfrom diabetes and in some people

with sciatica and complex regional pain

syndrome (reflex sympathetic dystrophy),as well as rheumatoid arthritis.

Pain from nerve damage can be verysevere and troublesome, for example thepain thats caused by spinal problems orthat follows a bout of shingles. This painmay respond to stronger opioids butoccasionally other drugs are used. Drugs

used to treat nerve damage can includeamitripyline, gabapentin and pregabalin.

AmitriptylineAmitriptyline is an antidepressant drugbut it also has painkilling and sedativeeffects. Its used in low doses (575 mg)2 hours before bed for nerve pain and forpeople who have chronic pain associated

with sleep disturbance. The dose is usuallycapped at 50 mg a day if it s only beingused for pain relief. It causes drowsinessand a dry mouth and some people canttolerate even low doses. You shouldnttake amitriptyline if you have certainforms of glaucoma.

Gabapentin and pregabalin

Gabapentin and pregabalin are alsodrugs which can be effective for nervepain. Like amitriptyline, they may begiven in combination with other painmedications in the most troublesomenerve pain conditions.


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What if I have problemswith my heart?If you have a serious heart condition,high blood pressure or uncontrolled highcholesterol, or if youre in severe cardiacfailure or have just had a heart attack,your doctor may advise you not to takeNSAIDs. This is because theres evidenceof a slight but important risk of future

cardiovascular problems. This risk mustbe weighed carefully against the benefityou get from NSAIDs, which may bemore effective than simple or compoundanalgesics if you have inflammatoryarthritis. Naproxen is generally felt tobe the least harmful NSAID in thesecircumstances. Coxibs are best avoidedif you have cardiovascular disease

unless you have a peptic ulcer and canttolerate NSAIDs combined with a protonpump inhibitor.

All NSAIDs, particularly diclofenac and

high dose ibuprofen, are associated witha slightly increased risk of developinga stroke.

Where can I get moreinformation?Arthritis Research UK is the charity leadingthe fight against arthritis. We do this byfunding high-quality research, providinginformation and campaigning. We publishover 60 information booklets which helppeople to understand more about theircondition, its treatment, therapies andhow to help themselves.

For more information on any ofthe conditions or individual drugs

mentioned here, see Arthritis ResearchUK range of booklets and drug leaflets,or speak to your doctor or rheumatologynurse specialist.

If you would like any further informationabout painkillers, or if you have anyconcerns about your treatment, youshould discuss this with your doctor,

rheumatology nurse or pharmacist.

Speak to yourdoctor if you haveany questionsabout painkillers

and other drugtreatments.


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Notes

Record your information here to help you manage your treatment:

What am I taking?

When/how often?

What dosage (if applicable)?

Hospital/clinic address:


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www.arthritisresearchuk.org

A team of people contributed to this booklet. The originaltext was written by Dr Mike Shipley and consultant in pain

medicine Dr John Lee, who have expertise in the subject.

It was assessed at draft stage by consultant rheumatologist

Prof. Bhaskar Dasgupta, FRP team leader/clinical assistant

spines Caroline Evans and consultant rheumatology

nurse Diana Finney. An Arthritis Research UKeditor

revised the text to make it easy to read, and a non-medical

panel, including interested societies, checked it for

understanding. An Arthritis Research UKmedical advisor,

Kate Gadsby, is responsible for the content overall.

Please note: We have made every effort to ensure

that this content is correct at time of publication, but

remember that information about drugs may change.

This information sheet is for general education

only and does not list allthe uses and side-effects

associated with this drug. For full details please see the

drug information leaflet that comes with your medicine.

Your doctor will assess your medical circumstances and

draw your attention to any information or side-effects that

may be relevant in your particular case.

This leaflet has been produced, funded and independently

verified by Arthritis Research UK .

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Tel 0300 790 0400calls charged at standard rate

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Painkillers Analgesics