Drug information
Painkillers
Painkillers
(analgesics)
This leaflet provides information on painkillers
and will answer any questions you have about
the treatment.
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, it’s still difficult to define.
Put simply, it’s usually a protective
mechanism that alerts your brain
when damage has occurred. Pain
is unpleasant, but it’s often shortlived and the reasons for it are
usually easy to understand, for
example if you’ve had a fall or
burnt yourself. You may decide
to take painkillers to ease the pain
until it gets better, and if you have
arthritis or a related condition you
may want to take them during
flare-ups. You can also take them
before you exercise to help
prevent pain.
Arthritis Research UK
Painkillers
What’s 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
of compound analgesics
11Which medications can help
with inflammatory arthritis?
11What medications are used
in nerve (neuropathic) pain?
– Amitriptyline
– Gabapentin and pregabalin
12What if I have problems
with my heart?
12Where can I get more
information?
7 Opioid analgesics
– Table 3: Common examples
of opioid analgesics
10What other drugs can help
ease pain?
– Disease-modifying
anti-rheumatic drugs (DMARDs)
and biological therapies
– Steroids
10Which medications can help
with osteoarthritis?
1
What are painkillers?
Painkillers are drugs that help to reduce
pain. When we talk about painkillers, we’re
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.
The approved name should always be
on the pharmacist’s label even if a brand
name appears on the packaging, but check
with your doctor, nurse or pharmacist if
you’re in any doubt. We’ll use the approved
names in the sections that follow.
You don’t 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 aren’t
as effective as they could be because
they don’t 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. It’s available in 500 mg
tablets or in liquid form for children.
It’s usually taken in doses of two 500 mg
tablets up to four times a day. It’s well
tolerated 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 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,
for example 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
as it’s not taken regularly or in doses
of more than 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
of painkiller
What are
they used
for?
Mild to moderate
pain, for example
headaches, injuries
and osteoarthritis,
or as an addition to
stronger painkillers
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
on prescription
stronger types are only
available on prescription
What are
Paracetamol has
the common few side-effects but
side-effects? high doses 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
I know?
Shouldn’t be used at high Can be used instead of
doses for long-term pain NSAIDs if these can’t be
taken for any reason
Paracetamol and some
Can cause more sideeffects compared with
non-opioid types
NSAIDs are available
as suppositories
3
Many different
NSAIDs are
available, so if one
doesn’t work you
can try others.
Paracetamol doesn’t have an antiinflammatory effect, which means it’s less
helpful for inflammatory arthritis, such
as rheumatoid arthritis, so it’s commonly
taken in combination with non-steroidal
anti-inflammatory drugs (NSAIDs). It’s
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.
They can be used in combination with
other simple or compound analgesics,
so they can be helpful even when
there’s not a great deal of inflammation,
for example in osteoarthritis.
NSAIDs start working within a few
hours. The effects of some will only last
for a few hours but others are effective
4
all day. 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.
It’s available over the counter in 300 mg
tablets and is usually taken in doses of
300–600 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,
as do enteric-coated tablets (which have
a coating to make sure the drug isn’t
absorbed into the body until it reaches
the small intestine), but you shouldn’t
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 shouldn’t use fish oil if you’re
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 shouldn’t
take aspirin.
Arthritis Research UK
Painkillers
Aspirin is also used in low doses (75 mg
daily) to reduce the risk of strokes and
heart attacks. This dose doesn’t have
a pain-relieving effect. If you’re on
long-term, low-dose aspirin you must
be careful about taking other NSAIDs
because it increases the risk of stomach
bleeding. Ask your doctor’s advice if
you’re unsure.
Ibuprofen
Ibuprofen is a widely used painkiller and
anti-inflammatory. It’s available over the
counter in doses of 200–400 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 shouldn’t
take more than one NSAID at a time.
NSAIDs can have serious side-effects and
shouldn’t be used long-term. Speak to
your doctor if you need longer term
pain relief.
For more information see Arthritis
Research UK drug leaflet
Non-steroidal anti-inflammatory drugs.
Compound analgesics
Compound analgesics are made from
a combination of two different drugs.
The most 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 doctor’s advice
if you’re pregnant or breastfeeding.
Older people may be advised to reduce
the maximum dose.
Common examples of compound
analgesics are listed on the next page
(see Table 2).
Compound
analgesics combine
two different
drugs. They’re
used for mild to
moderate pain.
5
Table 2 Common examples of compound analgesics
Type
6
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
I get 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
I know?
For more severe pain,
combinations of
15 mg/500 mg and
30 mg/500 mg
are available
For more severe pain,
combinations of
20 mg/500 mg and
30 mg/500 mg
are available
Arthritis Research UK
Painkillers
Opioid analgesics
Opioid analgesics can be more effective
for pain relief than simple non-opioid
analgesics, so they’re used for moderate
to severe pain. Pain is considered to be
severe if it’s 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 they’re
only available on prescription and you’ll
be monitored more closely by your doctor.
They’re only used if other analgesics
haven’t worked. In many cases they’re
used for short periods of time or alongside
other painkillers when necessary to reduce
the risk of side-effects and dependency.
All side-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
to severe 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
to your 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 you’re taking
(see Table 3).
7
Table 3 Common examples of Opioid analgesics
Type
Codeine and
dihydrocodeine
Tramadol
Buprenorphine
What are they?
The most widely
used weak
opioid analgesics
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?
30–60 mg up to four
times a day
50–100 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
or confused
Constipation, nausea,
drowsiness and
dizziness – avoided
for long-term use
whenever possible
Available in a
slow-release formula
of 100–200 mg for
severe pain
Also comes in a
tablet which is placed
under the tongue
for an immediate
painkilling effect
What else should
I know?
Available at various
strengths and in slowrelease formulas for
long-term pain
Can also be combined
with paracetamol,
which increases its
effectiveness
8
Patches may cause
an allergic reaction
where they’re 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
and strong 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
tablets or as slowrelease tablets
Dose varies according
to the severity of
the pain
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 they’re applied
to the skin
Also available in
lozenge form for
immediate pain relief
Morphine
Often causes
nausea and 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
a day to reduce sideeffects when used
long term
9
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 you’ve been diagnosed with a specific
type of arthritis, for example rheumatoid
arthritis, and they’re only available on
prescription. They work by altering the
underlying disease rather than treating
10
the symptoms. They’re not painkillers, but
they’ll 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 they’re very useful for
easing pain once they’ve started to work.
Steroids
Like DMARDs, steroids are only
used for certain types of arthritis,
including rheumatoid arthritis, lupus
and polymyalgia rheumatica (PMR).
They help to reduce inflammation,
which can ease pain.
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 won’t cure
your condition.
Which medications can
help with osteoarthritis?
If you have osteoarthritis you’ll probably
experience pain at times, so you should
use painkillers when it’s 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
if you have back or neck pain.
Arthritis Research UK
Painkillers
Which medications
can help with
inflammatory arthritis?
If you have inflammatory arthritis, such
as rheumatoid or psoriatic arthritis, you’ll
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
be prescribed 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 as often.
Other types of arthritis also cause pain
but require treatments that are more
specific, for example NSAIDs are very
effective in gout whereas analgesics
aren’t. You should speak to your doctor
if you’re 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 wouldn’t normally
hurt, such as gentle stroking of the skin.
This sometimes happens in complications
from 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 very
severe and troublesome, for example the
pain that’s 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. It’s used in low doses (5–75 mg)
2 hours 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 it’s only being
used for pain relief. It causes drowsiness
and a dry mouth and some people can’t
tolerate even low doses. You shouldn’t
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 pain conditions.
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 you’re in severe cardiac
failure or have just had a heart attack,
your doctor may advise you not to take
NSAIDs. This is because there’s 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 can’t
tolerate NSAIDs combined with a proton
pump inhibitor.
All NSAIDs, particularly diclofenac and
high dose ibuprofen, are associated with
a slightly increased risk of developing
a stroke.
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
mentioned here, see Arthritis Research
UK range of booklets and drug leaflets,
or speak to your doctor or rheumatology
nurse specialist.
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.
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 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.
This information sheet is for general education
only and does not list all the 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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© Arthritis Research UK 2011
Published September 2011 2258/D-PAIN/11-1
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