Many of us rely on popping a painkiller for common ailments such as headaches, hangovers, colds and flu. Over 6,000 tonnes of paracetamol are sold in the UK each year, and if you are one of the 20 million people suffering from musculoskeletal pain – most commonly back pain – you probably think nothing of swallowing a couple of ibuprofen to help.
But a new study has found that ibuprofen could make back pain worse, not better. Researchers analysed data from 500,000 adults in the UK Biobank scheme and found that those who took anti-inflammatory painkillers like ibuprofen as a short-term fix for back pain had a 70 per cent higher risk of developing chronic pain compared with those who took alternatives like paracetamol. Should we be reconsidering which painkillers we take for which condition?
Perhaps, says Dr Stephen Hughes, a senior lecturer in medicine at Anglia Ruskin University, but more likely we should consider how long we take them for. Over-the-counter painkillers should only ever be used “intermittently, not chronically, unless there’s a good medical reason to do so,” he says. “I think there’s mileage in this study. We know that, with headaches, if you take painkillers for a long period of time, you get an analgesic headache that doesn’t go away. I’m wondering if it could also prolong back pain.”
Here’s what you should take for common complaints, and when...
There are three main types of painkiller available over the counter, explains Hughes. “Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) that reduces the amount of certain compounds produced by our white blood cells to reduce inflammation, whereas paracetamol works more on the spinal cord and on nerves to inhibit the transmission of pain signals,” he explains. There’s another class of pain relief you can get over the counter in a low dose, and that’s codeine, which is an opioid, for more severe pain.”
For joint pain, back pain or muscle injuries where a sprain or tear has led to inflammation, ibuprofen is still the best choice for most people.Dr Franziska Denk, a senior lecturer and chronic pain expert at King’s College London, says: “We must remember that this study is quite preliminary, and they didn’t measure pain intensity – so nothing should change from NHS guidelines,” she says. Anti-inflammatory painkillers and using hot and cold compression packs should still be the go-to treatment for acute back pain.
Leanne May of Kingston University’s department of pharmacy says ibuprofen would also be the “first line” treatment for toothache and menstrual cramps, as both involve inflammation or spasms.
“For most general pain, we normally start with paracetamol,” says May. “It has no interactions with other medications and most people can take it quite safely.” It doesn’t have the same anti-inflammatory properties as ibuprofen, and simply reduces pain by blocking pain receptors. For headaches, colds, fevers and flu, it should do the job, but for more intense pain, it might not be enough.
The upside is that it can be taken any time, and it’s well tolerated by people who can’t have NSAIDs – for instance, those with a history of stomach ulcers or heart problems. “We think of ibuprofen as an easy over-the-counter medication, but if it’s taken long term or not with food it can have serious side effects,” says May. “GPs would only provide it for longer-term use with something to protect the lining of your gut.”
Aspirin is another common NSAID. “Aspirin is anti-inflammatory, and it’s what I take if I have aches and pains, and it works for me,” Hughes says. “There is no one size fits all for pain relief, which is why we have a range of drugs. Aspirin is slightly different to ibuprofen and works on a different pathway but has a similar side effect profile.”
As well as treating day-to-day pain and headaches, aspirin is used at low doses to reduce the risk of a heart attack or stroke in high-risk patients as it “stops platelets sticking together. It’s a real lifesaver, and something I use in my daily practice of emergency medicine for heart attacks,” adds Hughes. Low-dose aspirin should never be taken without a doctor's advice, as long-term use can cause serious side effects such as stomach ulcers.
May would recommend paracetamol in combination with codeine for treating more severe musculoskeletal pain. It works on the central nervous system to reduce pain by blocking signals between the body and the brain.
“You only get really low doses of opioids over the counter and always in combination,” May says, “so if you were recovering from surgery you would need something much stronger.” But for back pain or injuries where paracetamol doesn’t cut it, an over-the-counter combination of the two (called co-codamol) could do the trick. “We don’t recommend opioids for more than three days because they can cause addiction and other problems including constipation,” she says. “For a longer period, if any pain goes from acute to chronic, we would always suggest going to the GP.”