Drug information

Painkillers and NSAIDs

PAINKILLERS
AND NSAIDS
are types of drugs called analgesics,
which are used to treat pain.

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 Introduction What are painkillers and NSAIDs?
Painkillers and NSAIDs (non-steroidal anti-inflammatory drugs) Painkillers and NSAIDs, are types of drugs called analgesics, which
can help reduce pain, fever, and inflammation. are used to treat pain.

They can be used as short-term, self-care treatments, or may be The greatest difference is that painkillers target the levels of pain
prescribed in higher doses by your doctor to help manage the you’re feeling, by interrupting pain signals before they get to the brain.
effects of your condition. NSAIDs, which can also be called non-steroidal anti-inflammatory
drugs, help manage pain and fever, mostly by reducing inflammation.
You can talk about the benefits and risks of taking painkillers and
NSAIDs with a healthcare professional before you start treatment, However, if you have long term pain or inflammation, they are
so you’re able to make an informed decision. unlikely to improve the underlying problem that’s causing it.

We recommend using this contents list to find the specific painkiller Painkillers and NSAIDs you can buy
or non-steroidal anti-inflammatory drug (NSAID) you are interested
in learning more about. Some painkillers and NSAIDs are available to buy from pharmacies,
shops, or supermarkets. They are often recommended for managing
What are painkillers and NSAIDs? 3 mild to moderate pain yourself, over a short period of time.

Painkillers and NSAIDs you can buy 3 These include:

• the painkiller – paracetamol
Paracetamol 5
• NSAIDs – ibuprofen, aspirin, and diclofenac gel
NSAIDs 6 • compound painkillers – co-codamol, paracetamol and ibuprofen,
ibuprofen and codeine.
Compound painkillers 10
Your healthcare professional may also recommend using these
Antidepressants 12 drugs under their guidance over the long term, to help manage
Nefopam 14 your condition.

Opioid painkillers and painkilling patches 15 Most people can use over-the-counter pain relief. However, some may
need to be cautious. Seek advice from a pharmacist or healthcare
Effects of painkillers and NSAIDs on other treatments 18 professional before taking them if you:
Alcohol 19 • are underweight
• are aged under 16, or over 65
Fertility, pregnancy, and breastfeeding 20 • are pregnant or breastfeeding

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 • have lung problems, such as asthma Paracetamol
• have ever had fits or seizures
Paracetamol is used to reduce fever and can help manage mild to
• have allergies
moderate aches and pain. You can take paracetamol as a tablet,
• have persistent headaches capsule, liquid, or as tablets that dissolve in water. It should start
• have problems with your liver or kidneys working within the hour and last for around five hours.
• have had ulcers or bleeding in your stomach
• have had problems with your heart, liver, kidneys, blood pressure, Though paracetamol is safe for most people, your doctor may
or circulation advise against using it if you have another health issue.
• are taking other medicines If you have problems such as lower back pain, or osteoarthritis,
• have had a stroke taking paracetamol alone may not be the most effective treatment.
• drink more than 14 units of alcohol a week
You can take paracetamol with NSAIDs, such as ibuprofen or aspirin,
• have a condition affecting your connective tissue, such as lupus.
or with another painkiller called codeine.
Painkillers containing codeine should only be taken for three days
However, be careful if you’re taking medicines for migraines,
at most without medical advice. Taking other over-the-counter
coughs, colds and flu, or compound painkillers, because these drugs
drugs for longer than ten days without guidance from a healthcare
often already contain paracetamol.
professional, could increase your risk of side effects such as
problems with your stomach, heart, liver, or kidneys. Taking too much paracetamol can cause liver failure.
If over-the-counter drugs haven’t improved your pain your If paracetamol isn’t helping, a healthcare professional may
doctor may prescribe stronger pain medication or another recommend other treatments, such as a programme of exercise,
type of treatment. physiotherapy, or a stronger type of pain relief.

Risks and side effects

You
You should always check the manufacturer’s advice for guidance  can find more information about exercising with arthritis
on ingredients and how much you can take over 24 hours. in our Keep moving booklet. We also provide additional
information about the conditions mentioned above in our
Children, aged under 16, should not take aspirin unless it’s booklets Osteoarthritis and Back pain available through
prescribed by a doctor, as it can cause an illness called Reye’s our website www.versusarthritis.org
syndrome, which can damage the brain and liver, and could
be fatal.

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 NSAIDs They can be taken as either:
• tablets or capsules you swallow
NSAIDs, or non-steroidal anti-inflammatory drugs, are recommended
for short-term relief from pain, fever, and swelling or stiffness • a liquid you drink
around your bones and joints. • a suppository, a medicine you place in your bottom
• a cream, gel, spray, plaster, or mousse you apply to the skin –
You should feel some relief within an hour of using NSAIDs, but it known as topical NSAIDs.
can take several days or weeks before you feel the full benefit.
Your doctor should discuss with you the type of NSAID that’s
If you’ve been using over-the-counter NSAIDs, such as ibuprofen best for you, and they should arrange regular check-ups to review
or aspirin, your doctor may recommend you continue taking them your progress.
under their guidance, before considering another treatment.
NSAIDs may not be suitable for everyone. The type of NSAID you
These drugs can cause side effects, particularly if you take them for are prescribed may depend upon other health issues, such as if you:
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. • are over 65
• might be pregnant or you’re breastfeeding
There are around 20 NSAIDs that are commonly prescribed, • have asthma or allergies
these include: • have had a reaction to an NSAID
• ibuprofen • have had ulcers or bleeding in your stomach
• ketoprofen • have had problems with your heart, liver, kidneys, blood pressure,
• fenbufen or circulation
• piroxicam • are taking other medicines
• have had a stroke
• aspirin
• have problems with your stomach, intestines, or bowels such as
• naproxen ulcerative colitis or Crohn’s disease
• diclofenac • problems with your blood pressure, circulation, or bleeding
• indomethacin • have a condition affecting your connective tissue, such as lupus
• celecoxib • experience persistent headaches.
• etoricoxib.
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.

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 They are often recommended for treating isolated areas of pain Risks and side effects
and inflammation caused by osteoarthritis, particularly in the hands If you’re taking anti-coagulant drugs to thin your blood, such as low-
and knees. dose aspirin or warfarin, you’re best to avoid taking other NSAIDs or
Topical NSAIDs may not be helpful for people with inflammatory compound painkillers.
conditions, such as rheumatoid arthritis, because their pain is Even at low doses NSAIDs can cause side effects, such as:
more widespread.
• headaches
However, NSAIDs are considered the most effective way of relieving • dizziness
pain and inflammation caused by rheumatoid arthritis. • stomach pains, sickness, diarrhoea, and indigestion
NSAIDs can cause stomach problems so your doctor is likely to • bleeding
prescribe a drug called a proton-pump inhibitor (PPI), such as • swollen ankles
omeprazole or lansoprazole, to reduce the amount of acid in your • problems when you pee
stomach. • chest pains and difficulty breathing
Some NSAIDs, such as celecoxib, etoricoxib, are designed to be • a rash or sensitivity to sunlight.
gentler on your stomach. If you experience any side effects, stop taking the pain relief and
Depending on your condition, you may be prescribed other drugs, speak to your doctor.
such as disease-modifying anti-rheumatic drugs (DMARDs) or Long-term use of NSAIDs, can cause problems with the liver, kidney,
steroids. These drugs can help reduce your pain by treating the heart, and blood circulation.
condition that’s causing it.
NSAIDs can cause stomach problems and are best taken with food
You can use NSAIDs if you are taking paracetamol. However, you or a drink of milk to help reduce these side effects.
should be careful taking NSAIDs with compound painkillers because
some compound painkillers contain NSAIDs. If you’re aged over 65, some NSAIDs can increase your risk of
developing stomach ulcers. If you’re at risk of developing stomach
If you have concerns about taking NSAIDs seek advice from a problems or you get stomach pains after you’ve taken your NSAIDs,
healthcare professional. speak to your doctor.
NSAIDs can cause side effects and their long-term use should be
You
 can find out more about the conditions here in the monitored by a healthcare professional.
Versus Arthritis booklets Lupus, Osteoarthritis of the hand
and wrist, Osteoarthritis of the knee and Rheumatoid arthritis.
Or you can find out more at www.versusarthritis.org

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 Compound painkillers To avoid accidentally taking too much of any drugs, make sure
you know what your compound painkiller contains and avoid these
Compound painkillers combine two types of pain relief medication. ingredients while you’re taking it.
Some compound painkillers are available over the counter Because each of the ingredients can cause different side effects,
from a pharmacist, others can only be prescribed by a compound painkillers may increase your risk of an unpleasant
healthcare professional. reaction.
For example:
Risks and side effects
• co-codamol containing low-dose codeine and paracetamol, Compound painkillers can reduce your pain, but they may cause
available over the counter more side effects.
• paracetamol and ibuprofen tablets, available over the counter
• ibuprofen and codeine, available over the counter Compound painkillers containing aspirin, paracetamol, or ibuprofen,
• co-dydramol containing paracetamol and dihydrocodeine, carry the same risk of side effects as taking these drugs separately.
available on prescription Common side effects of compound painkillers include:
• co-codaprin containing codeine and aspirin, available on
prescription. • feeling sick
• drowsiness
Depending on what is causing your pain, your doctor is likely to • feeling dizzy
recommend you try paracetamol and NSAIDs, before prescribing • heartburn or indigestion
compound painkillers. • constipation.
Compound painkillers can be taken as tablets, capsules or People who take painkillers containing opioids can become
dissolved in water. dependent on them if they take them for a long period of time.
Healthcare professionals are unlikely to prescribe compound Ask your doctor’s advice before using compound painkillers if you’re
painkillers containing the opioids codeine and dihydrocodeine for pregnant or breastfeeding.
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.

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 Antidepressants Risks and side effects
Low dose antidepressants can be prescribed to treat long term, Many people take antidepressants without experiencing any
persistent pain. problems, but they can cause some side effects. Many of the more
common ones go once your body gets used to them.
These drugs were originally developed to treat anxiety and
depression. However, when taken at a lower dose they have been Side effects include:
found to effectively treat pain. Doctors are now being encouraged • constipation
to prescribe low dose antidepressants before other pain relief • dizziness
treatments. • dry mouth
If you are prescribed antidepressants, they can improve the way • feeling sleepy
your body responds to pain, your mood, emotional state, and • blurred eyesight
sleep quality. • difficulty peeing
• headache.
Antidepressants commonly recommended for pain include:
• amitriptyline If these side effects don’t improve speak to your doctor or
• citalopram pharmacist.
• duloxetine Occasionally people can experience weakness down one side
• fluoxetine of their body, or trouble speaking, thinking, or balancing. If you
• paroxetine experience these side effects seek urgent medical advice.
• sertraline. Some people also experience changes in their appetite and weight
These drugs may not be suitable for everyone. Because they when they start taking antidepressants, if this concerns you speak
weren’t originally designed to treat pain, your doctor may first to your doctor.
want to discuss the benefits and risks of prescribing them, before Some antidepressants can make you drowsy. You’re advised to
deciding whether an antidepressant would help your condition. avoid cycling, driving, or using machinery for the first few days of
Antidepressants can affect other conditions, including: taking them, until you know how they affect you.
• diabetes
• epilepsy You
 can find more information in the Versus Arthritis booklet
• heart problems Amitriptyline or on our website www.versusarthritis.org
• glaucoma
• overactive thyroid gland
• severe liver disease

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 Nefopam Opioid painkillers and painkilling patches
Nefopam is a non-opioid painkiller that can be prescribed to treat Opioid painkillers can be prescribed to offer relief from moderate to
pain, if NSAIDs and paracetamol have not helped. severe pain when other forms of pain relief haven’t worked.
It causes fewer breathing problems than opioid drugs. It can Some opioids are stronger than others. If your doctor feels your
sometimes be prescribed as an extra way of managing your pain pain can only be helped by opioids they will prescribe the lowest
with paracetamol, or NSAIDs such as ibuprofen or naproxen. dose, for the shortest time. Opioids are available as tablets, liquids,
or patches.
However, it has not been shown to be hugely beneficial to people
with long term pain and can cause several side effects. However, because of the risk of side effects such as addiction and
overdose, healthcare professionals are advised to avoid prescribing
Risks and side effects opioid painkillers for long-term pain, where possible.
Nefopam can cause side effects including:
If you are prescribed opioid painkillers your treatment should be
• nausea strictly monitored.
• nervousness
Opioid painkillers include:
• confusion or seeing things that aren’t there
• numbness and tingling in your hands or feet • codeine
• problems when you pee • dihydrocodeine
• dry mouth • tramadol
• feeling light-headed. • buprenorphine
• fentanyl
You may not be able to take nefopam if you: • morphine
• are epileptic or have ever had seizures • diamorphine
• have liver or kidney problems • oxycodone
• have problems peeing • tapentadol.
• have angle closure glaucoma.
The low-dose codeine used in compound painkillers is the only
If you are aged over 65 you may be more likely to feel confused opioid painkiller available without a prescription.
or to see things that aren’t there. Nefopam is not usually
Opioid patches
recommended during pregnancy.
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.

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 These patches usually contain either buprenorphine or fentanyl, If you have breathing problems, such as sleep apnoea, asthma,
which is slowly released into the body over a period of several days. or chronic obstructive pulmonary disease (COPD), speak to your
For guidance on how often you should change your patch, see the doctor before taking opioid painkillers.
patient information leaflet included in the pack.
Taking opioids with sedative drugs, such as diazepam, temazepam,
You should only wear one patch at a time, unless told otherwise or alcohol, can make you more likely to feel drowsy, dizzy, and
by your doctor. unable to concentrate.
You should keep the area the patch is stuck to away from any Opioid drugs can cause seizures. If you are taking antipsychotic
source of heat, such as a hot water bottle, electric blanket or heat or antidepressant drugs you could be more likely to experience
pads, or sunlight. This is because heat can cause too much of the seizures if you are prescribed the opioid drug tapentadol.
drug to be released into the blood stream too quickly.
Opioid painkillers can become addictive and should be used with
You should inform any healthcare professional treating you that you caution. Speak to your doctor if you feel they aren’t working at the
are using opioid patches, as they can interact with other drugs. prescribed dose, or you are still in pain after finishing a course of
opioid painkillers.
Risks and side effects
Your doctor may recommend you stop taking opioids. Depending
Opioid painkillers commonly cause more side effects than
on how long you have been taking them you may experience some
other pain treatments and they need to be strictly monitored
reactions, including:
by your doctor.
• tremors or muscle spasms
Risks and side effects of opioid painkillers include: • anxiety, sweating, or restlessness
• feeling or being sick • sickness, diarrhoea, or stomach cramps.
• problems going to the toilet
If you have been taking opioid painkillers for a long period of
• itching
time you should only stop taking them under the guidance of a
• drowsiness and dizziness healthcare professional, as suddenly stopping your treatment
• not being able to concentrate can be dangerous.
• 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.

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 Effects of painkillers and NSAIDs Complementary treatments
on other treatments Complementary treatments, such as herbal remedies, vitamins,
and supplements, are not tested the same way as painkillers
Many people with arthritis and related conditions will need to take
and NSAIDs, so it’s difficult to say whether they are safe
painkillers or NSAIDs, along with drugs that treat the underlying
to take together.
cause of their condition. The combination you take and the length
of time you take them for will depend on your condition. You should always tell the healthcare professional treating you
about any other medications you are taking, including complementary
For inflammatory types of arthritis, such as rheumatoid arthritis,
treatments, herbal remedies, vitamins, or supplements, before you
your doctors should recommend starting treatment with a disease-
start your prescribed medication.
modifying anti-rheumatic drug (DMARD), such as methotrexate.
DMARDs won’t stop your pain straight away, but once they start to Alcohol
work, you should be able to reduce or stop your pain relief drugs.
Most people who take painkillers or NSAIDs can drink alcohol in
If you have gout, you may be prescribed the anti-inflammatory drug moderation.
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 Alcohol can increase the risk of side effects of some painkillers and
another drug, such as allopurinol or febuxostat, in the longer term to NSAIDs. It’s a good idea to read the leaflet that comes with your
reduce the risk of having more gout attacks. drug to see what it says about drinking alcohol.

If you have osteoarthritis of the hand or knee, you can use capsaicin If you’ve just started taking opioid painkillers, or your dose is
cream to treat the affected joints several times a day, as well as increased, you’re advised to avoid drinking alcohol until you’ve
taking painkillers. settled on your medication. Alcohol and opioid painkillers can affect
your concentration and can make you sleepy.
If you’re taking medications for other conditions, you should speak
to your doctor or a pharmacist about possible interactions. 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
You
 can visit www.versusarthritis.org to find out more, or the week. Having two or three days each week when you don’t drink
order Versus Arthritis booklets for more information on
alcohol is good for you.
Allopurinol, Febuxostat and Methotrexate.
Talk to your doctor or a pharmacist if you have any concerns.

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 Fertility, pregnancy and breastfeeding Stopping opioids without help from your doctor or midwife can
be dangerous for yourself and your child, particularly in your first
If you’re planning to start a family or you become pregnant, trimester when it can cause miscarriage, and the last trimester
you should discuss your medication with your doctor as soon when it can increase the risk of birth complications and stillbirth.
as possible.
Paracetamol is usually the recommended pain relief option if you’re
You
pregnant or breastfeeding, but it’s a good idea to talk to your  can find more information in the Versus Arthritis
booklet Pregnancy and arthritis or on our website
healthcare professional about any medications.
www.versusarthritis.org
NSAIDs are not usually recommended in pregnancy, especially after
30 weeks, unless you’re advised to take them by your doctor.
Where to go for further information
In rare cases low-dose aspirin may be continued during pregnancy
but only under specialist care for severe conditions, including: This leaflet is a guide to painkillers and NSAIDs, their benefits and
potential side effects. If there’s anything else you’d like to know
• high blood pressure about any of the drugs mentioned here, just ask the healthcare
• certain other long-term conditions – such as lupus. professionals in charge of your care.
NSAIDs are considered safe to take if you are breastfeeding. You can also call our free helpline on 0800 5200 520, where our
trained advisors can offer information, support and advice on your
Low dose antidepressants are considered safe during pregnancy.
type of arthritis.
Paracetamol and opioid painkillers may be used during pregnancy,
although it is recommended that you do not use them regularly or
for long periods. Visit our website www.versusarthritis.org to find out more.

Taking opioids in pregnancy can increase the risk of your baby
having breathing problems, experiencing painful effects from Thank you!
withdrawal, and may affect their brain function in future. They A team of people helped us create this booklet. We would like to
should only be taken under the guidance of a doctor. thank Tim Richards, Naresh Rallmil and Sue Swift for helping us
with reviewing this booklet.
Some low doses of opioids, such as dihydrocodeine, are considered
safe if you’re breastfeeding, but you should avoid anything We would also like to give a special thank you to the people
containing codeine. who shared their opinions and thoughts on the booklet. Your
contributions make sure the information we provide is relevant
If you’re a pregnant woman who has been taking opioids every
and suitable for everyone.
day for a while, you shouldn’t suddenly stop using them without
speaking to your doctor.

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 NOTES NOTES

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