When wandering around the pharmacy and faced with a multitude of choices, how do we know what tablet is going to hit the spot?
Here at Healthwords, we'd usually say the right painkiller is the lowest strength painkiller that can solve the pain problem, hopefully reducing the risk of side effects from stronger medications. However, we've also all been there with a nasty toothache and just wanting to get it gone so go for the strongest one! Below we'll discuss options from strongest to weakest, although normally we'd say it is always best to start with the mildest pain relief (paracetamol) and work your way upwards to the strongest.
It's also worth knowing the different classes of painkiller, as some treat certain pains better than others. Within each class there are options in how you take your pain relief, from a cream or gel to tablets or dispersible solutions. If you're worried about taking pain relief for a long time or have other health conditions, it might be safest to start with a cream or gel, as less is absorbed into the system and therefore there are less side effects and risks.
This is the first step on the pain relief ladder, and with relatively few risks or side effects if taken as instructed. Paracetamol is well-tolerated and may be sufficient for occasional mild pain that occurs for just a brief time. For a drug that’s been around for more than 100 years, it’s not well understood how paracetamol works or which area of the brain it works on, but it likely stops chemical neurotransmitters from transmitting a pain message.
Non-steroidal anti-inflammatory drugs (NSAIDs) constitute a category of medications designed to alleviate pain and reduce inflammation. While ibuprofen is readily available over the counter at pharmacies, more potent NSAIDs like naproxen, diclofenac, or indometacin necessitate a prescription. When addressing pain relief, the hierarchy typically involves switching from paracetamol to ibuprofen as the second step, then combining the two as the third step. The fourth step entails pairing paracetamol with a stronger NSAID such as naproxen.
Ibuprofen shares similar pain-relieving properties with paracetamol but exhibits heightened efficacy in conditions like arthritis, characterised by inflamed joints contributing significantly to discomfort. Moreover, it proves effective in managing acute gout flare-ups, wherein a single joint, like the toe, becomes inflamed, leading to intense pain over several days or weeks.
NSAIDs exert their effects by targeting prostaglandins, hormones released during inflammation and found abundantly during menstrual periods. Consequently, NSAIDs are the preferred option for effectively alleviating menstrual pain, particularly when initiated a couple of days before its onset. Among the aforementioned NSAIDs, mefenamic acid is commonly prescribed for this purpose.
However, NSAIDs may stimulate increased gastric acid production, potentially causing discomfort, hence their recommendation for consumption with food. Moreover, they carry the risk of gastrointestinal bleeding, warranting caution among individuals with a history of bleeding, stomach ulcers, or the elderly. In cases of prolonged NSAID use, doctors may prescribe proton pump inhibitors to mitigate the risk of ulcer formation.
Newer medications targeting COX-2 receptors aim to reduce gastrointestinal bleeding risk but are typically administered under hospital specialist supervision. Additionally, NSAIDs may trigger certain types of asthma and exacerbate pre-existing kidney conditions, warranting avoidance in such scenarios. To counteract these side effects, often a proton pump inhibitor (PPI) will given alongside long-term treatment of NSAIDs.
Aspirin, although sometimes classified within the NSAID group, has dwindled in popularity as a preferred pain reliever, with its anti-inflammatory effects manifesting only at higher doses. However, it remains frequently employed at low doses to mitigate heart disease risk, primarily through its anti-platelet action rather than its analgesic or anti-inflammatory properties.
Opioids include a wide-ranging scope of pain relief, from codeine at the mildest end, to tramadol as a medium strength, and different forms of morphine at the strongest end. Side effects become more pronounced with stronger doses – commonly constipation, drowsiness and feeling dizzy, sick or slightly out of it. Certain people seem more susceptible to this “wooziness” than others.
You can buy a low dose of codeine phosphate or dihydrocodeine (they are very similar drugs) in the pharmacy, and it’s often combined with paracetamol (co-codamol or paramol), but higher doses are only available on prescription. On our ladder of pain relief, if you are unable to take ibuprofen for any reason, you can swap in a mild dose of codeine with paracetamol on the second step, and combine on the third step.
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