Drug information

Painkillers

Painkillers
(analgesics)
This leaflet provides information on painkillers
and will answer any questions you have about
thetreatment.

Arthritis Research UK produce

and print our booklets entirely
from charitable donations.

What is pain?
Although everyone understands
what we mean by the word
pain, its still difficult to define.
Putsimply, its usually a protective
mechanism that alerts your brain
when damage has occurred. Pain
is unpleasant, but its often shortlived and the reasons for itare
usually easy to understand, for
example if youve had a fall or
burnt yourself. You may decide
totake painkillers to ease the pain
until it gets better, and if you have
arthritis or a related condition you
may want totake them during
flare-ups. You can also take them
before youexercise to help
prevent pain.

Arthritis Research UK
Painkillers

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 examples

ofcompound analgesics

11 Which medications can help

with inflammatory arthritis?
11 What medications are used
innerve (neuropathic) pain?
Amitriptyline
Gabapentin and pregabalin

12 What if I have problems

withmyheart?
12 Where can I get more
information?

7 Opioid analgesics

Table 3: Common examples

ofopioid analgesics

10 What other drugs can help

easepain?

Disease-modifying
anti-rheumatic drugs (DMARDs)
and biological therapies
Steroids

10 Which medications can help

with osteoarthritis?

What are painkillers?

Painkillers are drugs that help to reduce
pain. When we talk about painkillers, were
usually referring to a group of drugs called
analgesics. There are three different types
of analgesics, as shown in Table 1.
Drugs may be available under several
different names. Each drug has an
approved (or generic) name but
manufacturers often give their own brand
or trade name to the drug as well. For
example, Nurofen and Panadol are brand
names for ibuprofen and paracetamol,
which are the approved names.
Theapproved name should always be
on the pharmacists label even if a brand
name appears on the packaging, but check
with your doctor, nurse or pharmacist if
youre in any doubt. Well use the approved
names in the sections that follow.
You dont need to wait until your pain is
severe to use analgesics. Take them as the
packet advises or as your doctor suggests.
Many people find that analgesics arent
as effective as they could be because
theydont take them correctly.

Simple non-opioid
analgesics
Simple non-opioid analgesics are the
most common type of analgesic. The
most common of these is paracetamol.
Paracetamol
Paracetamol is available over the counter
and is widely used as a painkiller for mild
to moderate pain, for example following
a minor injury, and for headaches and
muscular pains. Paracetamol will also
reduce a fever. Its available in 500 mg
tablets or in liquid form for children.
Itsusually taken in doses of two 500mg
tablets up to four times a day. Its well
tolerated with very few side-effects.
Somepeople develop a rash, butthis
isvery rare.
At doses higher than 4,000 mg
(eighttablets) per day, paracetamol can
seriously damage your liver. The number
you can buy at any one time is limited
because of this risk. Care must be taken
if you have liver problems or drink a lot
of alcohol. It must also be used in lower
doses if you have kidney problems.
Be aware that many other products,
forexample cold and flu medications,
contain paracetamol.

You can take

analgesics before
exercise to help
prevent pain.
2

Paracetamol is well tolerated during

pregnancy or breastfeeding as long
asitsnot taken regularly or in doses
ofmorethan 2,000 mg per day.

Arthritis Research UK
Painkillers

Table 1 Common examples of analgesics

Pain level
Mild

Moderate

Severe

Type
Simple non-opioid
analgesics
e.g. paracetamol, aspirin,
ibuprofen

Compound analgesics

Opioid analgesics

e.g. co-codamol, co-codaprin, e.g. codeine, tramadol,

co-dydramol
morphine

What are
they?

The most common

form of analgesic, also
including non-steroidal
anti-inflammatory
drugs(NSAIDs)

A combination of drugs
in one tablet, usually
including paracetamol,
aspirin and codeine

The strongest types

ofpainkiller

What are
they used
for?

Mild to moderate
pain, for example
headaches, injuries
andosteoarthritis,
or asan addition to
strongerpainkillers

Mild to moderate pain,

for example injuries and
osteoarthritis, or as an
addition to NSAIDs

Moderate to severe pain

caused by osteoarthritis,
or as an addition to
NSAIDs for severe pain

Where do I
get them?

Over the counter at

supermarkets and
chemists, although some
NSAIDs are only available
on prescription

Milder forms are available Only available

over the counter, but
onprescription
stronger types are only
available on prescription

What are
Paracetamol has
the common few side-effects but
side-effects? highdoses can cause
liver damage

Compounds made
Nausea and vomiting,
from codeine can cause
constipation, drowsiness
constipation, nausea and and dizziness
loss of concentration

NSAIDs have more

side-effects, particularly
on the stomach
What else
should
Iknow?

Shouldnt be used at high Can be used instead of

doses for long-term pain NSAIDs if these cant be
taken for any reason
Paracetamol and some

Can cause more sideeffects compared with

non-opioid types

NSAIDs are available

assuppositories

Many different
NSAIDs are
available, so if one
doesnt work you
can try others.

Paracetamol doesnt have an antiinflammatory effect, which means its less

helpful for inflammatory arthritis, such
as rheumatoid arthritis, so its commonly
taken in combination with non-steroidal
anti-inflammatory drugs (NSAIDs). Its
usually the first treatment recommended
for easing pain caused by osteoarthritis.

Non-steroidal anti-inflammatory
drugs (NSAIDs)
NSAIDs are a type of simple nonopioid analgesic. They help to reduce
inflammation, which reduces pain.
Theycan be used in combination with
other simple or compound analgesics,
sothey can be helpful even when
theres not a great deal of inflammation,
forexample in osteoarthritis.
NSAIDs start working within a few
hours. The effects of some will only last
for afewhours but others are effective
4

allday. Your doctor will help you to

find the best formula and dose for you.
There are now about 20 different NSAIDs
available, the most common being aspirin
and ibuprofen.
Aspirin
Aspirin is widely used as a painkiller for
mild to moderate pain. It can reduce
fever and has an anti-inflammatory effect.
Itsavailable over the counter in 300 mg
tablets and is usually taken in doses of
300600 mg four times a day after food.
Aspirin can cause stomach-related
side-effects at higher doses. Soluble
forms reduce this risk to some extent,
asdo enteric-coated tablets (which have
a coating to make sure the drug isnt
absorbed into the body until it reaches
the small intestine), but you shouldnt
take it if you have indigestion, heartburn
or a history of stomach ulcers. It can
cause serious bleeding in the digestive
system, particularly if you drink alcohol,
take the blood-thinning drug warfarin or
are over 60. For this reason many doctors
will now advise you to take some of the
newer NSAIDs such as ibuprofen for pain
relief because of the reduced risk of sideeffects. You shouldnt use fish oil if youre
taking aspirin because they can interact.
Aspirin can also make asthma worse and
can cause an allergic reaction that results
in rashes and hives. If you experience any
of these side-effects you must stop taking
aspirin immediately. Children and young
people under the age of 16 shouldnt
takeaspirin.

Arthritis Research UK
Painkillers

Aspirin is also used in low doses (75mg

daily) to reduce the risk of strokes and
heart attacks. This dose doesnt have
a pain-relieving effect. If youre on
long-term, low-dose aspirin you must
be careful about taking other NSAIDs
because it increases the risk of stomach
bleeding. Ask your doctors advice if
youre unsure.
Ibuprofen
Ibuprofen is a widely used painkiller and
anti-inflammatory. Its available over the
counter in doses of 200400 mg and
can be taken up to four times a day after
food. You can also use ibuprofen gels and
creams, which you rub directly onto the
affected area.
Stronger and slow-release NSAIDs are
available on prescription and can be used
for rheumatoid arthritis and other types
of inflammatory arthritis. You shouldnt
take more than one NSAID at a time.
NSAIDs can have serious side-effects and
shouldnt be used long-term. Speakto
your doctor if you need longer term
painrelief.
For more information see Arthritis
Research UK drug leaflet
Non-steroidal anti-inflammatory drugs.

Compound analgesics
Compound analgesics are made from
acombination of two different drugs.
Themost commonly used drugs in
compound analgesics are:
paracetamol

aspirin
codeine
dihydrocodeine.
These drugs are most commonly used
because they cause fewer, less severe
side-effects. Some compound analgesics
containing low doses of codeine are
available over the counter, but other
stronger ones are only available on
prescription. Ask your doctors advice
ifyoure pregnant or breastfeeding.
Olderpeople may be advised to reduce
the maximum dose.
Common examples of compound
analgesics are listed on the next page
(seeTable 2).

Compound
analgesics combine
two different
drugs. Theyre
used for mild to
moderate pain.
5

Table 2 Common examples of compound analgesics

Type

Co-codamol

Co-codaprin

Co-dydramol

What is it?

Codeine (8 mg) and

paracetamol (500 mg)

Codeine (8 mg) and

aspirin (400 mg)

Dihydrocodeine (10 mg)

and paracetamol
(500 mg)

What dose
can I take?

Up to two tablets four

times a day

Up to two tablets four

times a day with food

Up to two tablets four

times a day

Where do
Iget them?

Over the counter or on

prescription

On prescription

On prescription

What are
the most
common
side effects?

Constipation, nausea,
Constipation, nausea,
drowsiness and dizziness drowsiness, dizziness,
heartburn and
indigestion

Constipation, nausea,
drowsiness and dizziness

What else
should
Iknow?

For more severe pain,

combinations of
15 mg/500 mg and
30 mg/500 mg
areavailable

For more severe pain,

combinations of
20 mg/500 mg and
30 mg/500 mg
areavailable

Arthritis Research UK
Painkillers

Opioid analgesics
Opioid analgesics can be more effective
for pain relief than simple non-opioid
analgesics, so theyre used for moderate
tosevere pain. Pain is considered to be
severe if its disabling, meaning you have
to take more frequent rests or can only
walk or move awkwardly.
Opioid analgesics can cause more sideeffects than simple analgesics and can lead
to dependency and addiction, so theyre
only available on prescription and youll
be monitored more closely by your doctor.
Theyre only used if other analgesics
havent worked. In many cases theyre
used for short periods of time or alongside
other painkillers when necessary to reduce
the risk of side-effects and dependency.
Allside-effects are more common in older
people, so the dose may be reduced.
The most common side-effects with
opioid 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

Opioid analgesics
are reserved
for moderate
tosevere pain.

reduced ability to breath (respiratory

depression) 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, talk
toyour doctor.
Opioid analgesics come in a tablet or
patch. Your doctor will advise on which
type is best for you depending or the
severity of your pain, your age and any
other medication that youre taking
(seeTable 3).

Table 3 Common examples of Opioid analgesics

Type
Codeine and
dihydrocodeine

Tramadol

Buprenorphine

What are they?

The most widely

used weak
opioidanalgesics

Stronger than codeine

and dihydrocodeine
and may work in a
slightly different way

A strong opioid
analgesic for severe
pain but can also be
given at a low starting
dose when used as a
low-dose patch

What dose
can I take?

3060 mg up to four
times a day

50100 mg up to four
times a day

Available in slowrelease patches,

which have different
strengths and can last
a week

What are the

side-effects?

Constipation, nausea,
drowsiness and
dizziness so are
avoided for long-term
use whenever possible

Fewer side-effects
than other opioids,
but makes some
people feel very
fuzzy-headed
orconfused

Constipation, nausea,
drowsiness and
dizziness avoided
for long-term use
whenever possible

Available in a
slow-release formula
of 100200 mg for
severe pain

Also comes in a
tabletwhich is placed
under the tongue
for an immediate
painkilling effect

What else should

Iknow?

Available at various
strengths and in slowrelease formulas for
long-term pain

Can also be combined

with paracetamol,
which increases its
effectiveness

Patches may cause

an allergic reaction
where theyre applied
to the skin

Arthritis Research UK
Painkillers

Type
Fentanyl

Oxycodone

Methadone

A strong opioid
A strong opioid
analgesic used for
analgesic used after
severe, long-term pain surgery and for severe,
long-term pain

A strong opioid
occasionally used
for severe pain and
cancer pain

A long-acting
andstrong opioid

Prescribed as a patch Available in slowwhich is applied to the release tablets (MST),

skin every 3 days
which are usually
taken twice a day

Available in a variety
of strengths as
tabletsor as slowrelease tablets

Dose varies according

to the severity of
thepain

Can cause
constipation,
nausea,drowsiness
and dizziness

Often causes nausea

and vomiting,
constipation,
drowsiness and
dizziness

Often causes nausea

and vomiting,
constipation,
drowsiness and
dizziness

Patches may cause

an allergic reaction
where theyre applied
to the skin
Also available in
lozenge form for
immediate pain relief

Morphine

Often causes
nauseaand vomiting
as well as constipation,
drowsiness and
dizziness

Also available
as a liquid and a
suppository, or an
injection for very
severe pain

Less sedating than

morphine
usually taken twice
aday to reduce sideeffects when used
long term

Depending on what
type of arthritis you
have, your doctor
may prescribe specific
drugs for your pain.

What other drugs

can help ease pain?
A number of other drugs that work in
different ways to analgesics also help
to reduce pain. These include diseasemodifying anti-rheumatic drugs
(DMARDs) and steroids.

Disease-modifying anti-rheumatic
drugs (DMARDs) and biological
therapies
DMARDs (which include traditional
DMARDs, immunosuppressant DMARDs
and biological therapies) are only used
if youve been diagnosed with a specific
type of arthritis, for example rheumatoid
arthritis, and theyre only available on
prescription. They work by altering the
underlying disease rather than treating
10

the symptoms. Theyre not painkillers, but

theyll reduce pain, swelling and stiffness
over a period of weeks or months by
slowing down the disease and its effects
on the joints. It can take months before
they take effect, but theyre very useful for
easing pain once theyve started to work.

Steroids
Like DMARDs, steroids are only
used for certain types of arthritis,
including rheumatoid arthritis, lupus
and polymyalgia rheumatica (PMR).
Theyhelp to reduce inflammation,
whichcaneasepain.
Steroids can be given in tablet form or
as an injection. Steroid injections may be
offered to people with osteoarthritis if
they have inflammation in their affected
joints. Both injections and tablets work
very quickly, although they wont cure
your condition.

Which medications can

help with osteoarthritis?
If you have osteoarthritis youll probably
experience pain at times, so you should
use painkillers when its interfering with
your everyday life. Some people with
osteoarthritis will find that the pain
is more constant, making day-to-day
activities difficult, affecting concentration
and disturbing sleep. If your pain affects
you in these ways you may need to take
combinations of medications.
Taking combinations can also often help
ifyou have back or neck pain.

Arthritis Research UK
Painkillers

Which medications
canhelp with
inflammatory arthritis?
If you have inflammatory arthritis, such
as rheumatoid or psoriatic arthritis, youll
need to take a combination of drugs.
NSAIDs are more effective than analgesics
in relieving the pain and stiffness of
inflammatory arthritis. You may also
beprescribed one or more DMARDs such
as methotrexate and biological therapies
by a rheumatologist. These drugs ease
pain, swelling and stiffness, and reduce
the risk of longer term damage to the
joints. Once the DMARDs start to work
you may not need to take analgesics and
NSAIDs asoften.
Other types of arthritis also cause pain
but require treatments that are more
specific, for example NSAIDs are very
effective in gout whereas analgesics
arent. You should speak to your doctor
ifyoure unsure.

What medications
are used in nerve
(neuropathic) pain?
Nerve pain can be caused by damage
to nerves or nerve endings. This causes
the nerves to send pain signals to the
spinal cord spontaneously, without
needing a specific stimulus, or in response
to something that wouldnt normally
hurt, such as gentle stroking of the skin.
Thissometimes happens in complications
from diabetes and in some people

withsciatica and complex regional pain

syndrome (reflex sympathetic dystrophy),
as well asrheumatoid arthritis.
Pain from nerve damage can be very
severe and troublesome, for example the
pain thats caused by spinal problems or
that follows a bout of shingles. This pain
may respond to stronger opioids but
occasionally other drugs are used. Drugs
used to treat nerve damage can include
amitripyline, gabapentin and pregabalin.
Amitriptyline
Amitriptyline is an antidepressant drug
but it also has painkilling and sedative
effects. Its used in low doses (575 mg)
2hours before bed for nerve pain and for
people who have chronic pain associated
with sleep disturbance. The dose is usually
capped at 50 mg a day if its only being
used for pain relief. It causes drowsiness
and a dry mouth and some people cant
tolerate even low doses. You shouldnt
take amitriptyline if you have certain
forms of glaucoma.
Gabapentin and pregabalin
Gabapentin and pregabalin are also
drugs which can be effective for nerve
pain. Like amitriptyline, they may be
given in combination with other pain
medications in the most troublesome
nerve painconditions.

11

What if I have problems

with my heart?
If you have a serious heart condition,
high blood pressure or uncontrolled high
cholesterol, or if youre in severe cardiac
failure or have just had a heart attack,
your doctor may advise you not to take
NSAIDs. This is because theres evidence
of a slight but important risk of future
cardiovascular problems. This risk must
be weighed carefully against the benefit
you get from NSAIDs, which may be
more effective than simple or compound
analgesics if you have inflammatory
arthritis. Naproxen is generally felt to
be the least harmful NSAID in these
circumstances. Coxibs are best avoided
if you have cardiovascular disease
unless you have a peptic ulcer and cant
tolerate NSAIDs combined with a proton
pumpinhibitor.

All NSAIDs, particularly diclofenac and

high dose ibuprofen, are associated with
a slightly increased risk of developing
astroke.

Where can I get more

information?
Arthritis Research UK is the charity leading
the fight against arthritis. We do this by
funding high-quality research, providing
information and campaigning. We publish
over 60 information booklets which help
people to understand more about their
condition, its treatment, therapies and
how to help themselves.
For more information on any of
the conditions or individual drugs
mentionedhere, see Arthritis Research
UK range of booklets and drug leaflets,
or speak to your doctor or rheumatology
nursespecialist.
If you would like any further information
about painkillers, or if you have any
concerns about your treatment, you
should discuss this with your doctor,
rheumatology nurse or pharmacist.

Speak to your
doctor if you have
any questions
about painkillers
and other drug
treatments.
12

Arthritis Research UK
Painkillers

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:

13

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A team of people contributed to this booklet. The original

text was written by Dr Mike Shipley and consultant in pain
medicine Dr John Lee, who have expertise in the subject.
Itwas 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 UK editor
revised the text to make it easy to read, and a non-medical
panel, including interested societies, checked it for
understanding. An Arthritis Research UK medical 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.
Thisinformation sheet is for general education
only and does not list all the uses andside-effects
associated with this drug. Forfull 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.

Arthritis Research UK
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Arthritis Research UK 2011
Published September 2011 2258/D-PAIN/11-1
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