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Which OTC painkiller in a post-codeine world?

Low back pain enhanced by psychological factors - Featured Image


From February 1st next year, all codeine-based pain relief medications will become prescription-only. GPs may get a surge of patients asking for codeine prescriptions, but they will probably also get people asking them for good over-the-counter alternatives to the opioid. So what should they be telling their patients?

According to NPS MedicineWise, the best alternative for the short-term management of acute pain may be an paracetamol/ibuprofen combination pill, of which there are several OTC formulations on the Australian market.

NPS MedicineWise says the best treatment for mild pain is still paracetamol only or non-pharmacological measures, such as ice packs. But when that doesn’t do the trick, paracetamol/ibuprofen may prove more effective, as long as the patient is able to take an NSAID.

Evidence from a number of studies show that for acute pain, the combination is better for analgesia than either drug on its own, although it is not indicated for chronic pain. Paracetamol/ibuprofen has been found to be effective for a variety of pain states, including postoperative pain, dysmenorrhoea and musculoskeletal pain.

A Cochrane review has looked at the combination’s efficacy after wisdom tooth removal and found it better than either paracetamol or ibuprofen on its own for relieving pain six hours after the intervention.

Short-term studies have not identified any safety concerns for the combination other than those already known for the individual components, although one study found an increase in bleeding over 13 weeks, suggesting caution with long-term use.

Paracetamol is relatively safe, although inadvertent overdose is possible, but more precautions are needed with the use of ibuprofen. Lower doses are recommended for older people, and those with kidney disease, a history of peptic ulcers, asthma, high blood pressure or in pregnancy.

Another possible OTC alternative to codeine is diclofenac potassium, which has been shown to be effective in a variety of pain states, including acute lower back pain, tension-type headache, musculoskeletal pain, dysmenorrhoea and dental pain.

For chronic pain, analgesic medicines are only mildly effective and their use is recommended only as an adjunct (paracetamol) to non-pharmacological strategies, or in small doses for a short time (NSAIDs).

Source: NPS MedicineWise