Pain Relief

A snowHead

WORK IN PROGRESS expect long pauses, changes, additions, and edits.

I will try to link medical terms, wiki-style as they can be confusing. The reason we speak in code half the time is that each word has a specific meaning; although a partial tear of the lateral collateral ligament producing swelling, echymosis and pain on stressing the joint into varus might not mean much to you, to me it's a sprained knee.

I'll add a section about contraindications - who shouldn't take what, etc

PART I

This thread comes from an idea on another thread, which was met with some support.

Some Background
I am a GP working in England. I see many people in pain, and sorting out rational and effective pain relief strategies is really a core part of my job. I have, in addition to my GP training, experience in Accident & Emergency medicine, Orthopaedics, and pre-hospital emergency care (and General Surgery, Urology, General Medicine, Paediatrics, etc etc etc...)

I'm not the only Doctor on Snowheads, and I would welcome any contributions from others.

Disclaimer
This article aims to inform the reader about the various modalities of pain relief available over the counter (OTC) at pharmacies, and how they may be combined. It is not intended to replace formal medical advice and should not be taken as an alternative to seeing a Registered Medical Practitioner.

The authors of linked images retain their copyright, and are used with acknowledgment.

Mr Donkey is an imaginary character.

Always read the label and patient information. Not all drugs suit everybody. It is your responsibilty to check. If in any doubt, ask your Pharmacist.

If you are pregnant or breast feeding, never take anything without asking your pharmacist first.

If you are taking any other medication (especially for asthma, bronchitis / COPD, antidepressants or 'sedatives') check with your pharmacist.

Scope
This article is really based at acute soft tissue injuries and not fractures, dislocations, fracture-dislocations or chronic (=ongoing) problems. If in doubt, see a Doctor.

Case Vignette
Mr Donkey is a 37 year old man who fell while negotiating the bumps under the Nauchets chair in Les Gets. He felt some pain immediately on the medial (inside) aspect of his left knee, but was able to continue skiing for the rest of the day. On arriving back at his appartment, he noticed some pain and bruising around the knee, which appeared slightly swollen compared to the other. He could bear his full weight on his injured leg, and could move his knee fully.

It is likely that Mr Donkey has sprained his medial collateral ligament

Pain Relief
Non-Pharmacological
--Compression can help reduce swelling, and was always advised as part of the RICE (rest, ice, compression, elevation) treatment for soft tissue injuries. The easiest way to compress is to use a tubular bandage (eg Tubigrip). These should be applied double (ie folded back on itself) and over an adequate length of the limb - for a knee, from mid thigh to mid shin at least; for an ankle, from knee to toes

--Non-adhesive bandages, like the old Crepe bandages are more awkward to apply correctly, but can achieve greater compression. Coban (and similar) is a bandage that sticks to itself, but not to skin and can offer a high degree of compression and support. Remember you're not trying to cut the blood supply off, so if your toes go blue or white Shocked

, it's too tight.

--Rest can help, but sometimes at the cost of the joint stiffening

--Cold (a bag of frozen peas wrapped in a tea towel) can help reduce pain and swelling. If you're skiing, there'll be lots of cold stuff just lying around on the ground. Wrap it in a scarf or hat et voila! instant cold compress.

--Elevation (raise the affected part above the level of the heart) can help reduce swelling.

--Exercise - keeping the joint moving is important from an early stage, to avoid problems with restricted movements later on

So, in summary You are probably best doing a bit of everything. Rest, exercise, compression and elevation. Personally, I'd favour exercise over rest.

A snowHead

PART II

Pharmacological (Drugs)
You can think of pain relievers (analgesics) as belonging to three 'ladders'. You can use one drug from each ladder, so it's perfectly reasonable to take, if needs be, three different anlagesics, each (again, if needs be) at their maximum doses.

BUT - and this is important 'ladder 3' drugs are only available OTC in combination with a drug from one of the other ladders. You must be careful not to accidentally take more than the maximum recommeded dose of any of the three 'ladders' of drug - so whilst (total daily doses) 8 paracetamol and 8 ibuprofen is OK, as is 8 paracet & 8 nurofen plus (which contains ladders 2&3); 8 paracet and 4 solpadeine max is not OK as you'd be taking the equivalent of 12 paracetamol tablets, along with the codeine.

Ladder 1
This ladder contains one drug, Paracetamol (Acetaminophen if you're over the pond).

The dose for adults is 1g (generally, 2 x 500mg tablets) four times a day (ie six-hourly)

Ladder 2
This ladder contains the non-steroidal anti inflammatory drugs (NSAIDs), such as ibuprofen, ketoprofen, diclofenac and aspirin. They are good pain killers, and reduce inflammation. They can cause stomach irritation commonly, which can be reduced by taking the drug with food. They are available in various forms - oral (tablets, solution) and topical (gels and creams). Ibuprofen is available to buy OTC (and aspirin, of course), while the others are only available as tablets on prescription. You can think of Ibuprofen being the bottom 'rung' of this ladder, with ketoprofen and diclofenac on the rungs above.

Ibuprofen, ketoprofen and diclofenac are available as gels; I use topical ketoprofen a lot. Topical diclofenac is expensive and I don't think has much benefit over its cheaper rivals.

The doses vary by drug, so read the packet! Ibuprofen for adults is generally used at a dose of 200-400mg, four times a day. Most OTC brands advise a maximum dose of 1200mg a day (ie 400mg three times a day)

They can cause breathing problems, and so asthmatics are often advised to avoid them. In 15 years of practice, I have seen two cases of asthma being worsened by NSAIDs, so it's an uncommon problem.

I'd also advise against using topical and oral NSAIDs together.

Avoid these drugs if you have had a stomach ulcer or duodenal ulcer. Some asthmatics may get problems if they take them, caution is advised

Ladder 3
Opiates (opioids). These drugs are related to morphine, and are potent analgesics. Codeine and dihydrocodeine are available OTC in the UK, as part of a combination with paracetamol.
Solpadeine Max tablets, for instance contain (per tablet) 500mg paracetamol and 12.8mg codeine. Paramol tablets contain Paracetamol 500mg and Dihydrocodeine Tartrate 7.46mg. Co-codamol tablets contain 500mg paracetamol and 8mg codeine. Think of these brands as a combo of ladders 1&3

Side effects of opiate analgesics include nausea Going green

vomiting

and drowsiness. Which is why you shouldn't drink (much) alcohol with them. Or ski, probably. And consti...pa.......tion Mad

; it will bung you up. (now - this can be useful, of course).

You can also buy an ibuprofen/codeine tablet (Nurofen Plus) which contains ibuprofen 200mg and codeine 12.8mg This is a combo of ladders 2 & 3

Although the official maximum dose of (say) dihydrocodeine is 240mg/day, it would be impossible to reach this without overdosing on the other constituent of the tablet; Taking 2 Solpadeine Max tablets four times a day would deliver 4g of paracetamol (the MAXIMUM dose in any case, ever. Do not exceed this!) and 102.4mg of codeine.

I have found that 24mg of codeine (2 nurofen plus) makes me very light-headed and want to lie down. Treat these drugs with respect. They're not smarties.

Use with caution. These are pharmacy-only drugs, check with the pharmacist

Confused

yet?

Well, the person's real but it's just a made up name, see?

PART III

A pain relief strategy

Poor Mr Donkey's knee is beginning to ache a bit, he's had the knee up, and has applied a double tubigrip from mid thigh to his ankle. He takes this off before going to bed.

Step 1

2x500mg paracetamol four times a day Ladder 1

If you can, take painkillers 'by the clock', so four times a day = 6 hourly. (eg: 12mn, 6am, 12md, 6pm). You can take paracetamol every 4 hours, but to a maximum of four times a day (eg 8am, 12md, 5pm, 11pm) but as you can see this leaves a big gap (11pm-8am) with no painkiller.

Step 2

Mr Donkey's up early, and finds his knee's a bit stiff. He spends a few minutes gently moving it, and it soon feels better. He takes his paracetamol (a bit later than 6am, but never mind) and heads off up the mountain. But by 11, his knee is aching again, so he returns to the appartment.

Mr Donkey knows about these ladders, and decides to continue with ladder 1 (paracetamol) and add in a drug from ladder 2. He has some Ibuprofen tablets and some ketoprofen gel. He's wearing lots of layers, and his tubigrip, and so feels that he'd prefer to take a couple of tablets rather than un-layer to apply the gel.

2x500mg paracetamol four times a day ladder 1
and
2x 200mg ibuprofen three or four times a day ladder 2

You can take these together, or alternate them:

P=paracetamol; I=ibuprofen

12mn...P 1
1am
2
3.........I 2
4
5
6.........P 1
7
8
9.........I 2
10
11
12md...P 1
1pm
2
3.........I 2
4
5
6.........P 1
7
8
9.........I 2
10
11

The advantage of doing this is that you are getting some pain relief every 3 hours, but of course you're having to wake up at 3am and 6am! As long as you leave at least 4 hours between doses, you can shuffle the timings around to suit you.

Taking the ibuprofen every 8 hours (three times a day) is often easier; say at 8am, 4pm and midnight.

I tend to use something like

12mn...P I 1 & 2
8am.....P I 1 & 2
12md...P 1
4pm.....I 2
6pm.....P 1

Step 3

Mr Donkey's knee is a little better but he didn't sleep well. He knows he can use a little bit of codeine along with his paracetamol and ibuprofen.

So he replaces his midnight dose of paracetamol (2 x 500mg tablets) with 2 'solpadeine max'. These contain the paracetamol dose he was taking, and 12.8 mg of codeine, so his pain relief plan now looks like (and this time it starts at 8am). C=codeine

8am.....P I 1 & 2
12md...P 1
4pm.....I 2
6pm.....P 1
12mn...I P C 1, 2 & 3

Step 4

If you need this level of pain relief, it's time to seek a professional opinion.

2x Ibuprofen 200mg four times a day 2
2x Paracetamol 500mg + codeine 8mg four times a day 1 & 3

or

2x Paracetamol 500mg + codeine 12.8mg four times a day 1 & 3
2x Ibuprofen 200mg four times a day 2

or

2x Paracetamol 500mg four times a day (note:no codeine) 1
2x Ibuprofen 200mg + codeine 12.8mg four times a day 2 & 3

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PART IV

Mr Donkey wonders whether he should buy paracetamol at 15p for 16 or Anadin at £1.99

Mr Donkey is quite right to wonder this, and it's a bit of a hobby horse of mine, so you'll excuse me if I go into rant-mode

Before I do, I'll say a few words on Aspirin. Aspirin has an interesting history; it is a NSAID derived initially from the bark of the willow. It is an effective analgesic, anti-inflammatory and antipyretic (lowers fevers). But it can - often - be extremely irritant to the stomach. It's dose is confusing too, being 300-325mg per tablet, and the dose instructions being 3 tablets; it's simpler, more effective, and safer to stick with ibuprofen. Plus you can use ibuprofen in children; Aspirin is adults only.

OK, back on track. Name a painkiller. No, name three. I bet you thought 'Anadin'. The UK's most widely-selling (I think) analgesia.

Anadin Original, Anadin Extra, Anadin Extra Soluble, Anadin Paracetamol, Anadin Paracetamol Soluble, Anadin Ultra Double Strength. All very confusing.

Anadin Original - 325mg Aspirin BP and 15mg Caffeine Ph Eur. Caffeine? That's not a painkiller, that's a cup of coffee.

but it gets worse

Anadin Extra 300mg of Aspirin BP, 200mg of Paracetamol Ph Eur and 45mg of caffeine Ph Eur. OK, this contains ladders 1 (paracet), 2 (aspirin) and more coffee. But note the dose of paracetamol - 200mg. The dose of paracetamol for an adult is 1g (1000mg) - so should you take 5 anadin extra? Well, no - because you'd be taking 1500mg of aspirin. And a lot of coffee.

And worse

Looking on http://www.mypharmacy.co.uk/ I see the price for 16 Anadin paracetamol tablets is £1.99 for 16 tablets

Tesco's Paracetamol tablets 500mg £0.15 for 16

A no-brainer.

I buy Paracetamol. No brand, just paracetamol. Same for Ibuprofen.

Anyway, snowHeads is much more fun if you do.

PART V

Mr Donkey wonders if there's anything else he could do

When to rest

The short answer is, I suppose, when you're not exercising. Be guided by the pain. Rest with the affected limb elevated.

When to exercise

Umm, when you're not resting rolling eyes

If the pain is being controlled with paracetamol / ibuprofen alone, I can't think of any reason why you shouldn't move the joint, unless you've received advice to rest completely.

What exercise

You want to be working on range of movement, to avoid stiffening. Try to split the movement of the joint into its separate components - for instance you can move your head around in circles, but that movement is a compound of the neck flexing (chin on chest), lateral flexion (ear on shoulder), extension (chin up) and rotation (chin on shoulder)

There is a lot of information on the web about exercises. As ever, information from the internet is not a substitute for good advice.

Where can I get advice

Doctors
Pharmacists
Physiotherapists
Osteopaths
Chiropractors

Are all regulated in the UK.

Sports Therapists
Holistic Healers
Massage Therapists

are not.

One question to ask any potential 'therapist' is how much insurance do they hold? To give you some indication, my personal liability indemnity covers me for an unlimited amount. If a cash limited amount, most GPs would hold indemnity covering them for £10,000,000 in any one claim.

It's not better

Stop browsing the web and see someone qualified

I'm getting side effects

Most side effects are dose-related, and reducing the dose is all you'd have to do. The list of side effects for any drug is long, and if you do experience any, it's worth checking the patient information leaflet that's in the box.

Paracetamol hardly ever causes problemd
NSAIDs cause tummy upsets; if you get severe pain after taking one, stop & seek medical advice
Codeine & similar - nausea, constipation, drowsiness

Read the leaflet.

Can I drink alcohol on these tablets?

OK I'm not telling you to get piddled. However, alcohol can be an effective analgesic, especially if there's muscle spasm. I had whiplash a few years ago, and my neck pain settled after 2 pints better than it did after paracetamol / ibuprofen.

Alcohol & paracetamol - generally OK
Alcohol & NSAIDs - increased risk of stomach irritation (even stomach ulcers)
Alcohol & opiates - Avoid. Effects of both (and side effects) greatly enhanced.

What do I need a prescription for?

In the UK, NSAIDs other than ibuprofen / aspirin (exceptions: topical); opiates other than the cases mentioned above.

I live in France / Canada / USA, and I can't get any codeine OTC

I have no experience in prescribing anywhere but the UK. I am told you can't buy any codeine-contaning products in the US. (But their Vicks decongestant contains amphetamine). I have never tried to obtain any medication abroad, so any contributions on this point would be welcomed

My brother's wife's sister's boyfriend has got this rash on his face. What do you think it could be?

Sorry, don't know. Tell him to see a doctor. The internet is no place for personal medical advice.

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Thanks for that, very informative. Look forward to reading the rest of it.

Then you can post your own questions or snow reports...

Great stuff, thanks. Can't wait for the next instalment. There can't be a single snowHead for whom this isn't relevant! Toofy Grin

After all it is free

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doctor_eeyore,

Please correct me if I am wrong but I think your post is potentially misleading and could be slightly dangerous.

'You can use one drug from each ladder' - quoted DE

But if you take Paracetomol from Ladder 1, Ibuprofen from Ladder 2 and Solphadeine from Ladder 3 then unless caution is taken it would be possible to OD on Paracetomol.
If I am correct and Solphadeine is actually a combo drug of Ladder 1 & 3 then please make this clear so that an innocent mistake is not made.

Thanks for starting this post though i hope it grows into a truly unique .... and free service for us all when in pain!

snowHeads are a friendly bunch.

snow reports

doctor_eeyore, Good luck with the thread it is highly altruistic of you!

doctor_eeyore, Thank you! I've always known you could take more than one type of painkiller but didn't know why, what or how!! I'm printing this out and packing it in my suitcase next trip so that I can follow the timing plans (god forbid that I'll need it but you just never know...)

You know it makes sense.

Great thread - could you just add a warning about avoiding NSAID's if you've had problems with stomach ulcers - can you tell that I've done a GI job dealing with the consequences.......

Otherwise you'll just go on seeing the one name:

I'd like to confuse the issue by adding another class of analgesics to the mix. There is a drug called bromelin that is based on pineapple extract. Orthopaedic surgeons in germany use it almost as a first line analgesic as it seems to have very few side effects. I use it a lot after keep fit and when taken in combination with a non steroidal anti-inflammatory tablet is eliminates the pain and swelling. Everyone has a different response to pain killers but I thought it worth mentioning this buy over the counter (in Boots) drug. Its one side effect in me is abdominal cramps ,which can be debilitating, and explosive fa#ts

A snowHead

A snowHead

k, Contraindications coming up!

Well, the person's real but it's just a made up name, see?

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Really good series of posts doctor_eeyore. Very clear.

Anyway, snowHeads is much more fun if you do.

doctor_eeyore, re double tubigrip:

My view has always been to cut the bit of tubigrip into two and puts both bits on as you describe. If you don't do this the turned over end may tend to cut in a bit (in my experience).

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slippy piste, welcome to snowheads.
A literature search finds 325 articles for Bromelain and 54 articles for Bromelin .
In none of them are either of these agents being used as an analgesic.
Unless you can find data to the contrary, I would suggest that Bromelain or Bromelin has no useful analgesic properties.

Then you can post your own questions or snow reports...

I think I have a fairly high pain threshold, so maybe that has an effect.
I have found the pain medications you speak of to be of little to no use. The only ones I can recall being of any benefit was a couple of Tylenol 3s (with codeine) washed down with about 10 oz of hard licquor. I have since learned that that is not good for the liver. Oxy-codone on the other hand seems to work. If you're in pain 'cause you broke your leg or what have you, get your doctor to give you a proper prescription. If you don't need one, then just suck it up!

After all it is free

Ghost, I think you may have misunderstood the term Pain Threshold.
Your post suggests that standard analgesics don't work for you: you need something stronger.
i.e. you feel pain earlier than others, or the stumulus threshold to cause pain in less than the average
You therefore have a Low Pain Threshold
But, of course, nothing is quite that simple: see here.

Ghost - can you buy paracetamol / codeine combos in Canada?

*Ski* the Net with snowHeads

Ghost, Oxycodone is a controlled drug in the UK, so not likely to be available to anyone with a broken leg, even with a prescription. Tramadol or Paracetamol and Codeine would be more likely to be prescribed.

snowHeads are a friendly bunch.

doctor_eeyore, (or any of the others who are knowledgeable about these things), what's the difference between codeine as contained in Solpadeine Max or Nurofen Plus and dihydrocodeine in Paramol? Is it effectively the same thing? Or does one work better than the other, or is it the combination with aspirin or paracetamol that makes the difference?

Sorry, I hope that makes sense. It's just that I've used Paramol and Nurofen Plus before and Paramol always seems much stronger/more effective

Excellent thread BTW, thanks for taking the time to compile all this info Very Happy

snow reports

doctor_eeyore, I was simply pointing out to Ghost that it was unlikely to be prescribed in the UK for a sports injury.

You know it makes sense.

samharris, dyhydrocodeine is stronger than codeine.

Otherwise you'll just go on seeing the one name:

samharris,

There's no practical difference between the two; I find dihydrocodeine (DHC) better tolerated. But YMMV. Interestingly, Paramol (paracetamol 500mg + DHC 7.46mg) should be less effective than Nurofen+ or sol.max (which have 12+mg codeine).

But I agree with you. DHC is better Very Happy

A snowHead

doctor_eeyore, I have recently been introduced to Syndol, over the counter tablets containing paracetamol,codeine, caffeine and doxylamine succinate. They are powerful - apart from the obvious paracetamol and codeine painkilling combo, the doxylamine succinate seems to be highly drowsy inducing, and relaxing, and can make for a good night's sleep. I have googled that element, which is apparently an anti-histamine, and there are some internet rubbishy "drugs without prescription" websites selling it in more powerful doses as a sleeping tablet - v. expensive.

Because of the extra help with sleeping (dunno how that sits with the caffeine element....) these pills are very useful at times, especially if pain might otherwise keep you awake. Given the propensity of people not to sleep on ski holidays, Syndol could be a useful addition to the armoury. But I can't help thinking that there must also be some snags. Obviously the codeine in big quantities can be habit-forming. What about the doxylamine succinate?

Final question; my daughter has very had period pain and migraines. She can't tolerate codeine - acute nausea and vomiting. Does anyone know of any other over the counter stuff which includes the doxylamine succinate, but without codeine.

A snowHead

doctor_eeyore, I stand corrected.
In clinical practice it appears that codeine and dihydrocodeine are equipotent
(paragraph 6.2)

Well, the person's real but it's just a made up name, see?

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I find syndol very good if travelling to the slopes on a coach through the night - helps me sleep

Anyway, snowHeads is much more fun if you do.

One minor point
When doctors say drug x is stronger or better than drug y what they really mean is that in a trial of a number of patients drug x appeared on average to have a greater effect than drug y. If drug y appears to work better for you than drug x then you should carry on taking it without being persuaded that the other one is better IMO.

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T Bar, excellent advice, and put very well.

Then you can post your own questions or snow reports...

doctor_eeyore,

After all it is free

doctor_eeyore,

the thing about syndol is it seems to have nice stuff, in an "over the counter" package. the caffeine is neither here nor there, and certainly doesn't seem to counteract the considerable sedative effect of the pills. Whatever is wrong, be it an injury, or something like a heavy cold, they seem to give you a very good night, for very little money! Kitty, I had a totally, horribly, bruised left leg from hip to ankle, caused by a fall on the ice rink in Chamonix. Just an unlucky fall, similar falls had not resulted in a similar injury before! It took months to disappear. Went all colours in the meantime.

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pam w, caffeine is there to increase the analgesic effect.

Help!!

Pain Relief

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